gender reassignment patients

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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 .

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Vaginoplasty for Gender Affirmation

Featured Experts:

Fan Liang, M.D.

Andrew Jason Cohen, M.D.

Vaginoplasty is a surgical procedure for  feminizing  gender affirmation. Fan Liang, M.D. , medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health , and Andrew Cohen, M.D. , director of benign urology at Johns Hopkins' Brady Urological Institute , review the options for surgery.

What is vaginoplasty?

Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum.

During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a feminine-appearing outer genital area with a shallow vaginal canal.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

For penile inversion vaginoplasty , surgeons create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Robotic-assisted peritoneal flap vaginoplasty , also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (vulva) with a very shallow canal. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take three to six months to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Illustrated Vaginoplasty Surgery

Vaginoplasty.

1 of 4 in series. Enlarged image .

2 of 4 in series. Enlarged image .

3 of 4 in series. Enlarged image .

4 of 4 in series. Enlarged image .

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for one to five days. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. You will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate three times a day for at least 20 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common, and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. After vaginoplasty that includes creation of a vaginal canal, a person can have receptive, penetrative sex.

You must avoid any form of sexual activity for 12 weeks after surgery to allow your body to recover and avoid complications. After 12 weeks, the vagina is healed enough for receptive intercourse.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 5 and 7 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.

Find a Doctor

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DAVID A. KLEIN, MD, MPH, SCOTT L. PARADISE, MD, AND EMILY T. GOODWIN, MD

Am Fam Physician. 2018;98(11):645-653

Related editorial: The Responsibility of Family Physicians to Our Transgender Patients

See related article from Annals of Family Medicine : Primary Care Clinicians' Willingness to Care for Transgender Patients

Patient information: A handout on this topic is available at https://familydoctor.org/lgbtq-mental-health-issues/

Author disclosure: No relevant financial affiliations.

Persons whose experienced or expressed gender differs from their sex assigned at birth may identify as transgender. Transgender and gender-diverse persons may have gender dysphoria (i.e., distress related to this incongruence) and often face substantial health care disparities and barriers to care. Gender identity is distinct from sexual orientation, sex development, and external gender expression. Each construct is culturally variable and exists along continuums rather than as dichotomous entities. Training staff in culturally sensitive terminology and transgender topics (e.g., use of chosen name and pronouns), creating welcoming and affirming clinical environments, and assessing personal biases may facilitate improved patient interactions. Depending on their comfort level and the availability of local subspecialty support, primary care clinicians may evaluate gender dysphoria and manage applicable hormone therapy, or monitor well-being and provide primary care and referrals. The history and physical examination should be sensitive and tailored to the reason for each visit. Clinicians should identify and treat mental health conditions but avoid the assumption that such conditions are related to gender identity. Preventive services should be based on the patient's current anatomy, medication use, and behaviors. Gender-affirming hormone therapy, which involves the use of an estrogen and antiandrogen, or of testosterone, is generally safe but partially irreversible. Specialized referral-based surgical services may improve outcomes in select patients. Adolescents experiencing puberty should be evaluated for reversible puberty suppression, which may make future affirmation easier and safer. Aspects of affirming care should not be delayed until gender stability is ensured. Multidisciplinary care may be optimal but is not universally available.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort .

eTable A provides definitions of terms used in this article. Transgender describes persons whose experienced or expressed gender differs from their sex assigned at birth. 5 , 6 Gender dysphoria describes distress or problems functioning that may be experienced by transgender and gender-diverse persons; this term should be used to describe distressing symptoms rather than to pathologize. 7 , 8 Gender incongruence, a diagnosis in the International Classification of Diseases , 11th revision (ICD-11), 9 describes the discrepancy between a person's experienced gender and assigned sex but does not imply dysphoria or a preference for treatment. 10 The terms transgender and gender incongruence generally are not used to describe sexual orientation, sex development, or external gender expression, which are related but distinct phenomena. 5 , 7 , 8 , 11 It may be helpful to consider the above constructs as culturally variable, nonbinary, and existing along continuums rather than as dichotomous entities. 5 , 8 , 12 , 13 For clarity, the term transgender will be used as an umbrella term in this article to indicate gender incongruence, dysphoria, or diversity.

Optimal Clinical Environment

It is important for clinicians to establish a safe and welcoming environment for transgender patients, with an emphasis on establishing and maintaining rapport ( Table 1 ) . 5 , 6 , 8 , 11 , 12 , 14 – 21 Clinicians can tell patients, “Although I have limited experience caring for gender-diverse persons, it is important to me that you feel safe in my practice, and I will work hard to give you the best care possible.” 22 Waiting areas may be more welcoming if transgender-friendly materials and displayed graphics show diversity. 5 , 12 , 14 , 15 Intake forms can be updated to include gender-neutral language and to use the two-step method (two questions to identify chosen gender identity and sex assigned at birth) to help identify transgender patients. 5 , 16 , 23 Training clinicians and staff in culturally sensitive terminology and transgender topics, as well as cultural humility and assessment of personal internal biases, may facilitate improved patient interactions. 5 , 21 , 24 Clinicians may also consider advocating for transgender patients in their community. 12 , 14 , 15 , 21

MEDICAL HISTORY

When assessing transgender patients for gender-affirming care, the clinician should evaluate the magnitude, duration, and stability of any gender dysphoria or incongruence. 8 , 12 Treatment should be optimized for conditions that may confound the clinical picture (e.g., psychosis) or make gender-affirming care more difficult (e.g., uncontrolled depression, significant substance use). 6 , 11 , 17 The support and safety of the patient's social environment also warrants evaluation as it pertains to gender affirmation. 6 , 8 , 11 This is ideally accomplished with multidisciplinary care and may require several visits to fully evaluate. 5 , 6 , 8 , 17 Depending on their comfort level and the availability of local subspecialty support, primary care clinicians may elect to take an active role in the patient's gender-related care by evaluating gender dysphoria and managing hormone therapy, or an adjunctive role by monitoring well-being and providing primary care and referrals ( Figure 1 ) . 5 , 6 , 8 , 11 – 15 , 17 , 19 , 21 , 22

Clinicians should not consider themselves gatekeepers of hormone therapy; rather, they should assist patients in making reasonable and educated decisions about their health care using an informed consent model with parental consent as indicated. 5 , 17 Based on expert opinion, the Endocrine Society recommends that clinicians who diagnose gender dysphoria or incongruence and who manage gender-affirming hormone therapy receive training in the proper use of the Diagnostic and Statistical Manual of Mental Disorders , 5th ed., and the ICD; have the ability to determine capacity for consent and to resolve psychosocial barriers to gender affirmation; be comfortable and knowledgeable in prescribing and monitoring hormone therapies; attend relevant professional meetings; and, if applicable, be familiar with lifespan development of transgender youth. 6

PHYSICAL EXAMINATION

Transgender patients may experience discomfort during the physical examination because of ongoing dysphoria or negative past experiences. 4 , 5 , 8 Examinations should be based on the patient's current anatomy and specific needs for the visit, and should be explained, chaperoned, and stopped as indicated by the patient's comfort level. 5 Differences of sex development are typically diagnosed much earlier than gender dysphoria or gender incongruence. However, in the absence of gender-affirming hormone therapy, an initial examination may be warranted to assess for sex characteristics that are incongruent with sex assigned at birth. Such findings may warrant referral to an endocrinologist or other subspecialist. 6 , 25

Mental Health

Transgender patients typically have high rates of mental health diagnoses. 11 , 18 However, it is important not to assume that a patient's mental health concerns are secondary to being transgender. 5 , 12 , 15 Primary care clinicians should consider routine screening for depression, anxiety, posttraumatic stress disorder, eating disorders, substance use, intimate partner violence, self-injury, bullying, truancy, homelessness, high-risk sexual behaviors, and suicidality. 5 , 11 , 14 , 15 , 19 , 26 – 29 Clinicians should be equipped to handle the basic mental health needs of transgender persons (e.g., first-line treatments for depression or anxiety) and refer patients to subspecialists when warranted. 5 , 8 , 15

Because of the higher prevalence of traumatic life experiences in transgender persons, care should be trauma-informed (i.e., focused on safety, empowerment, and trustworthiness) and guided by the patient's life experiences as they relate to their care and resilience. 5 , 15 , 30 Efforts to convert a person's gender identity to align with their sex assigned at birth—so-called gender conversion therapy—are unethical and incompatible with current guidelines and evidence, including policy from the American Academy of Family Physicians. 6 , 8 , 11 , 12 , 14 , 15 , 17 , 31

Health Maintenance

Preventive services are similar for transgender and cisgender (i.e., not transgender) persons. Nuanced recommendations are based on the patient's current anatomy, medication use, and behaviors. 5 , 6 , 32 Screening recommendations for hyperlipidemia, diabetes mellitus, tobacco use, hypertension, and obesity are available from the U.S. Preventive Services Task Force (USPSTF). 33 Clinicians should be vigilant for signs and symptoms of venous thromboembolism (VTE) and metabolic disease because hormone therapy may increase the risk of these conditions. 5 , 6 , 34 Screening for osteoporosis is based on hormone use. 6 , 35

Cancer screening recommendations are determined by the patient's current anatomy. Transgender females with breast tissue and transgender males who have not undergone complete mastectomy should receive screening mammography based on guidelines for cisgender persons. 6 , 36 Screening for cervical and prostate cancers should be based on current guidelines and the presence of relevant anatomy. 5 , 6

Recommendations for immunizations (e.g., human papillomavirus) and screening and treatment for sexually transmitted infections (including human immunodeficiency virus) are provided by the Centers for Disease Control and Prevention and USPSTF based on sexual practices. 32 , 33 , 37 , 38 Pre- and postexposure prophylaxis for human immunodeficiency virus infection should be considered for patients who meet treatment criteria. 32 , 38

Hormone Therapy

Feminizing and masculinizing hormone therapies are partially irreversible treatments to facilitate development of secondary sex characteristics of the experienced gender. 6 Not all gender-diverse persons require or seek hormone treatment; however, those who receive treatment generally report improved quality of life, self-esteem, and anxiety. 5 , 6 , 39 – 44 Patients must consent to therapy after being informed of the potentially irreversible changes in physical appearance, fertility potential, and social circumstances, as well as other potential benefits and risks.

Feminizing hormone therapy includes estrogen and antiandrogens to decrease the serum testosterone level below 50 ng per dL (1.7 nmol per L) while maintaining the serum estradiol level below 200 pg per mL (734 pmol per L). 6 Therapy may reduce muscle mass, libido, and terminal hair growth, and increase breast development and fat redistribution; voice change is not expected. 5 , 6 The risk of VTE can be mitigated by avoiding formulations containing ethinyl estradiol, supraphysiologic doses, and tobacco use. 34 , 45 – 47 Additional risks include breast cancer, prolactinoma, cardiovascular or cerebrovascular disease, cholelithiasis, and hypertriglyceridemia; however, these risks are rare (yet clinically significant), indolent, or incompletely studied. 5 , 6 , 36 , 48 Spironolactone use requires monitoring for hypotension, hyperkalemia, and changes in renal function. 5 , 6

Masculinizing hormone therapy includes testosterone to increase serum levels to 320 to 1,000 ng per dL (11.1 to 34.7 nmol per L). 6 Anticipated changes include acne, scalp hair loss, voice deepening, vaginal atrophy, clitoromegaly, weight gain, facial and body hair growth, and increased muscle mass. Patients receiving masculinizing hormone therapy are at risk of erythrocytosis, as determined by male-range reference values (e.g., hematocrit greater than 50%). 5 , 6 , 45 , 49 Data on patient-oriented outcomes (e.g., death, thromboembolic disease, stroke, osteoporosis, liver toxicity, myocardial infarction) are sparse. Despite possible metabolic effects, few serious events have been identified in meta-analyses. 6 , 34 , 35 , 45 , 46 , 49

Active hormone-sensitive malignancy is an absolute contraindication to gender-affirming hormone treatment. 5 Patients who are older, use tobacco, or have severe chronic disease, current or previous VTE, or a history of hormone-sensitive malignancy may benefit from individualized dosing regimens and subspecialty consultation. 5 The benefits and risks of treatment should be weighed against the risks of inaction, such as suicidality. 5 The use of low-dose transdermal estradiol-17 β (Climara) may reduce the risk of VTE. 5

Some patients without coexisting conditions may prefer a lower dose or individualized regimen. 5 All patients should be offered referral to discuss fertility preservation or artificial reproductive technology. 5 , 20 Table 2 5 , 6 , 17 , 22 , 50 and eTable B present surveillance guidelines and dosing recommendations for patients receiving gender-affirming hormone therapy.

Surgery and Other Treatments

Gender-affirming surgical treatments may not be required to minimize gender dysphoria, and care should be individualized. 6 Mastectomy (i.e., chest reconstruction surgery) may be performed for transmasculine persons before 18 years of age, depending on consent, duration of applicable hormone treatment, and health status. 6 Breast augmentation for transfeminine persons may be timed to maximal breast development from hormone therapy. 5 , 6 Mastectomy or breast augmentation generally costs less than $10,000, and insurance coverage varies. 51 Patients may also request referral for facial and laryngeal surgery, voice therapy, or hair removal. 5 , 6 , 8

The Endocrine Society recommends that persons who seek fertility-limiting surgeries reach the legal age of majority, optimize treatment for coexisting conditions, and undergo social affirmation and hormone treatment (if applicable) continuously for 12 months. 6 Adherence to hormone therapy after gonadectomy is paramount for maintaining bone mineral density. 6 Despite associated costs, varying insurance coverage, potential complications, and the potential for prolonged recovery, 6 , 8 , 51 gender-affirming surgeries generally have high satisfaction rates. 6 , 42

Transgender Youth

Most, but not all, transgender adults report stability of their gender identity since childhood. 17 , 52 However, some gender-diverse prepubertal children subsequently identify as gay, lesbian, or bisexual adolescents, or have other identities instead of transgender, 8 , 11 , 17 , 53 – 55 as opposed to those in early adolescence, when gender identity may become clearer. 5 , 8 , 11 , 17 , 43 , 44 , 53 , 55 There is no universally accepted treatment protocol for prepubertal gender-diverse children. 6 , 12 , 17 Clinicians may preferentially focus on assisting the child and family members in an affirmative care strategy that individualizes healthy exploration of gender identity (as opposed to a supportive, “wait-and-see” approach); this may warrant referral to a mental health clinician comfortable with the lifespan development of transgender youth. 6 , 12 , 13 , 21

Transgender adolescents should have access to psychological therapy for support and a safe means to explore their gender identity, adjust to socioemotional aspects of gender incongruence, and discuss realistic expectations for potential therapy. 6 , 8 , 12 , 17 The clinician should advocate for supportive family and social environments, which have been shown to confer resilience. 14 , 18 , 21 , 40 , 56 , 57 Unsupportive environments in which patients are bullied or victimized can have adverse effects on psychosocial functioning and well-being. 21 , 58 , 59

Transgender adolescents may experience distress at the onset of secondary sex characteristics. Clinicians should consider initiation of or timely referral for a gonadotropin-releasing hormone (GnRH) to suppress puberty when the patient has reached stage 2 or 3 of sexual maturity. 5 , 6 , 8 , 17 , 21 , 40 , 44 This treatment is fully reversible, may make future affirmation easier and safer, and allows time to ensure stability of gender identity. 6 , 17 No hormonal intervention is warranted before the onset of puberty. 6 , 8 , 17

Consent for treatment with GnRH analogues should include information about benefits and risks 5 , 6 , 8 , 15 , 50 ( eTable B ) . Before therapy is initiated, patients should be offered referral to discuss fertility preservation, which may require progression through endogenous puberty. 5 , 6

Some persons prefer to align their appearance (e.g., clothing, hairstyle) or behaviors with their gender identity. The risks and benefits of social affirmation should be weighed. 5 , 6 , 8 , 13 , 17 , 56 Transmasculine postmenarcheal youth may undergo menstrual suppression, which typically provides an additional contraceptive benefit (testosterone alone is insufficient). 5 Breast binding may be used to conceal breast tissue but may cause pain, skin irritation, or skin infections. 5

Multiple studies report improved psychosocial outcomes after puberty suppression and subsequent gender-affirming hormone therapy. 39 – 42 , 44 , 60 Delayed treatment may potentiate psychiatric stress and gender-related abuse; therefore, withholding gender-affirming treatment in a wait-and-see approach is not without risk. 8 Additional resources for transgender persons, family members, and clinicians are presented in eTable C .

Data Sources: PubMed searches were completed using the MeSH function with the key phrases transgender, gender dysphoria, and gender incongruence. The reference lists of six cited manuscripts were searched for additional studies of interest, including three relevant reviews and guidelines by the World Professional Association for Transgender Health; the Center of Excellence for Transgender Health at the University of California, San Francisco; and the Endocrine Society. Other queries included Essential Evidence Plus and the Cochrane Database of Systematic Reviews. Search dates: November 1, 2017, to September 18, 2018.

The views expressed in this publication are those of the authors and do not reflect the official policy or position of the Departments of the Army, Navy, or Air Force; the Department of Defense; or the U.S. government.

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Joint R, Chen ZE, Cameron S. Breast and reproductive cancers in the transgender population: a systematic review [published online ahead of print April 28, 2018]. BJOG . https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.15258 . Accessed August 25, 2018.

Jacobeit JW, Gooren LJ, Schulte HM. Safety aspects of 36 months of administration of long-acting intramuscular testosterone undecanoate for treatment of female-to-male transgender individuals. Eur J Endocrinol. 2009;161(5):795-798.

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Kailas M, Lu HM, Rothman EF, Safer JD. Prevalence and types of gender-affirming surgery among a sample of transgender endocrinology patients prior to state expansion of insurance coverage. Endocr Pract. 2017;23(7):780-786.

Landén M, Wålinder J, Lundström B. Clinical characteristics of a total cohort of female and male applicants for sex reassignment: a descriptive study. Acta Psychiatr Scand. 1998;97(3):189-194.

Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013;52(6):582-590.

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Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

Valeria p. bustos.

From the * Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Samyd S. Bustos

† Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

Andres Mascaro

‡ Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Weston, Fla.

Gabriel Del Corral

§ Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.

Antonio J. Forte

¶ Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Fla.

Pedro Ciudad

∥ Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

Esther A. Kim

** Division of Plastic and Reconstructive Surgery, University of California, San Francisco, Calif.

Howard N. Langstein

†† Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y.

Oscar J. Manrique

Associated data.

Supplemental Digital Content is available in the text.

Background:

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin’s regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions:

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Introduction

Discordance or misalignment between gender identity and sex assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria. 1 – 3 This population has increased risk of psychiatric conditions, including depression, substance abuse disorders, self-injury, and suicide, compared with cis-gender individuals. 4 , 5 Approximately 0.6% of adults in the United States identify themselves as transgenders. 6 Despite advocacy to promote and increase awareness of the human rights of transgender and gender non-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals. 4 , 7

Gender-affirmation care plays an important role in tackling gender dysphoria. 5 , 8 – 10 Gender-affirmation surgeries (GAS) aim to align the patients’ appearance with their gender identity and help achieve personal comfort with one-self, which will help decrease psychological distress. 5 , 10 These interventions should be addressed by a multidisciplinary team, including psychiatrists, psychologists, endocrinologists, physical therapists, and surgeons. 1 , 9 The number of GAS has consistently increased during the last years. In the United States, from 2017 to 2018, the number of GAS increased to 15.3%. 8 , 11 , 12

Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented. 5 , 13 – 19 However, despite this, there is a minor population that experiences regret, occasionally leading to de-transition surgeries. 20 Both regret and de-transition may add an important burden of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should be paid in identifying and recognizing the prevalence and factors associated with regret. In the present study, we hypothesized that the prevalence of regret is less than the last estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation care. Therefore, the aim of this study was to evaluate the prevalence of regret and assess associated factors in TGNB patients 13-years-old or older who underwent GAS. 20

Search Methodology

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive research of several databases from each database’s inception to May 11, 2020, for studies in both English and Spanish languages, was conducted. 21 The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced librarian, with input from the study’s principal investigator. Controlled vocabulary supplemented with keywords was used to search for studies of de-transition and regret in adult patients who underwent gender confirmation surgery. The actual strategy listing all search terms used and how they are combined is available in Supplemental Digital Content 1. ( See Supplemental Digital Content 1, which displays the search strategy. http://links.lww.com/PRSGO/B598 .)

Study Selection

Search results were exported from the database into XML format and then uploaded to Covidence. 22 The study selection was performed in a 2-stage screening process. The first step was conducted by 2 screeners (V.P.B. and S.S.B.), who reviewed titles and abstracts and selected those of relevance to the research question. Then, the same 2 screeners reviewed full text of the remaining articles and selected those eligible according to the inclusion and exclusion criteria (Fig. ​ (Fig.1). 1 ). If disagreements were encountered, a third reviewer (O.J.M.) moderated a discussion, and a joint decision between the 3 reviewers was made for a final determination. Inclusion criteria were all the articles that included patients aged 13 years or more who underwent GAS and report regret or de-transition rates, and observational or interventional studies in English or Spanish language. Exclusion criteria were letter to the editors, case series with <10 patients, case reports correspondences, and animal studies.

PRISMA flow diagram for systematic reviews.

Data Extraction/Synthesis

After selecting the articles, we assessed study characteristics. We identified year of publication, country in which the study was conducted, population size, and number of transmasculine and transfemenine patients with their respective mean age (expressed with SD, range, or interquartile range if included in the study). In addition, we extracted information of the method of data collection (interviews versus questionnaires), number of regrets following GAS, as well as the type of surgery, time of follow-up, and de-transition procedures. We classified the type of regret based on the patient’s reasons for regret if they were mentioned in the studies. We used the Pfäfflin and Kuiper and Cohen-Kettenis classifications of regret (Table ​ (Table1 1 ). 20 , 23

Pfäfflin and Kuiper and Cohen-Kettenis Categories of Regret

Quality Assessment

To assess the risk of bias within each study, the National Institute of Health (NIH) quality assessment tool was used. 24 This tool ranks each article as “good,” “fair,” or “poor,” and with this, we categorized each article into “low risk,” “moderate risk,” or “high risk” of bias, respectively.

Our primary outcome of interest was the prevalence of regret of transgender patients who underwent any type of GAS. Secondary outcomes of interest were discriminating the prevalence of regrets by type gender transition (transfemenine and transmasculine), and type of surgery.

Data Analysis and Synthesis

The binominal data were analyzed, and the pooled prevalence of regret was estimated using proportion meta-analysis with Stata Software/IC (version 16.1). 25 Given the heterogeneity between studies, we conducted a logistic-normal-random-effect model. The study-specific proportions with 95% exact CIs and overall pooled estimates with 95% Wald CIs with Freeman-Turkey double arcsine transformation were used. The effect size and percentage of weight were presented for each individual study. 25 , 26

To evaluate heterogeneity, I 2 statistics was used. If P < 0.05 or I 2 > 50%, significant heterogeneity was considered. A univariate meta-regression analysis was performed to assess the significance in country of origin, tools of measurement, and quality of the studies.

To assess publication bias, we used funnel plot graphic and the Egger test. If this test showed us no statistical significance ( P > 0.05), we assumed that the publication bias had a low impact on the results of our metanalysis. To assess the impact of the publication bias on our missing studies, we used the trim-and-fill method.

A sensitivity analysis was conducted to assess the influence of certain characteristics in the magnitude and precision of the overall prevalence of regret. The following characteristics were excluded: <10 participants included, and the presence of a high risk of bias.

A total of 74 articles were identified in the search, and 2 additional records were identified through other sources. After the first-step screening process, 39 articles were relevant based on the information provided in their titles and abstracts. After the second-step process, a total of 27 articles were included in the systematic review and metanalysis (Fig. ​ (Fig.1 1 ).

Based on the NIH quality assessment tool, the majority of article ranged between “poor” and “fair” categories. 24 ( See Supplemental Digital Content 2, which displays the score of each reviewed study. http://links.lww.com/PRSGO/B599 .)

Study Characteristics

In total, the included studies pooled 7928 cases of transgender individuals who underwent any type of GAS. A total of 2578 (33%) underwent transmasculine procedures, 5136 (67%) underwent transfemenine surgeries, and 1 non-binary patient underwent surgery. In Table ​ Table2 2 characteristics of studies are listed. Without discriminating type of surgical technique, from all transfemenine surgeries included, 772 (39.3%) were vaginoplasty, 260 (13.3%) were clitoroplasty, 107 (5.5%) were breast augmentation, 72 (3.7%) were labioplasty and vulvoplasty, and a small minority were facial feminization surgery, vocal cord surgery, thyroid cartilage reduction, and oophorectomy surgery. The rest did not specify type of surgery. In regard to transmasculine surgeries, 297 (12.4%) were mastectomies, 61 (2.6%) were phalloplasties, and 51 (2.1%) hysterectomies (Table ​ (Table3 3 and ​ and4). 4 ). Overall, follow-up time from surgery to the time of regret assessment ranged from 0.8 to 9 years (Table ​ (Table2 2 ).

*Reflects the mean of both transmasculine and transfemenine.

†Includes both scheduled and completed surgery.

‡Includes both surgery and no surgery patients.

H, High; He, Heterosexual; Ho, Homosexual; I, Interview; IQR, Interquartile Range; L, Low; M, Moderate; Me, Median; NA, Not applicable; NS: Not specified, Q: Questionnaire; RAP: Radial Arterial Forearm-Flap Phalloplasty without or with cutaneous nerve to clitoral nerve anastomosis; SP: Suprapubic Pedicle-Flap Phalloplasty.

Studies Differentiating Type of Surgery among Transfemenine Patients

Studies Differentiating the Type of Surgery among Transmasculine Patients

Regrets and De-transition

Almost all studies conducted non-validated questionnaires to assess regret due to the lack of standardized questionnaires available in this topic. 15 , 19 – 33 Most of the questions evaluating regret used options such as, “ yes,” “sometimes,” “no” or “ all the time,” “sometimes,” “never,” or “most certainly, ” “very likely,” “maybe,” “rather not,” or “definitely not.” 14 , 18 , 19 , 23 , 27 – 38 Other studies used semi-structured interviews. 34 , 37 , 39 – 43 However, in both circumstances, some studies provided further specific information on reasons for regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44 – 46 Of the 7928 patients, 77 expressed regret (12 transmen, 57 transwomen, 8 not specified), understood by those who had “sometimes” or “always” felt it.

Reasons for Regret

The most prevalent reason for regret was the difficulty/dissatisfaction/acceptance in life with the new gender role. 23 , 29 , 32 , 36 , 44 Other less prevalent reasons were “failure” of surgery to achieve their surgical goals in an aesthetic level and psychological level. 29 , 32 , 36 , 47 Based on the reasons presented, we classified the types of regrets according to Pfäfflin’s types of regret and Kuiper and Cohen-Kettenis classification. According to Pfäfflin’s types, 28 patients had minor regret, and 34 patients had major regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44 , 45 Based on the Kuiper and Cohen-Kettenis regret classification, 35 patients had clear regret, 26 uncertain regret, 1 regret, and none presented with regret assumed by others. 23 In Table ​ Table5 5 and ​ and6, 6 , the reasons and classifications are shown.

Type of Regret

*8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation.

N, no; NS, not specified; Y, Yes.

Causes of Regret

NS, not specified.

Prevalence of Regret

The pooled prevalence of regret among the TGNB population after GAS was 1% (95% Confidence interval [CI] <1%–2%; I 2 = 75.1%) (Fig. ​ (Fig.2). 2 ). The prevalence for transmasculine surgeries was <1% (CI <1%–<1%, I 2 = 28.8%), and for transfemenine surgeries, it was 1% (CI <1%–2%, I 2 = 75.5%) (Fig. ​ (Fig.3). 3 ). The prevalence of regret after vaginoplasty was of 2% (CI <1%–4%, I 2 = 41.5%) and that after mastectomy was <1% (CI <1–<1%, I 2 = 21.8%) (Fig. ​ (Fig.4 4 ).

Pooled prevalence of regret among TGNB individuals after gender confirmation surgery. Heterogeneity χ 2 = 104.31 (d.f. = 26), P = 0.00, I 2 [variation in effect size (ES) attributable to heterogeneity] = 75.08%, Estimate of between-study variance Ʈ 2 = 0.02, Test of ES = 0, z = 4.22, P = 0.00.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender confirmation surgery based on gender. ES, effect size.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender confirmation surgery based on the type of surgery. ES, effect size.

Meta-regression and Publication Bias

No covariates analyzed affected the pooled endpoint in this metanalysis. The Funnel Plot shows asymmetry between studies (Fig. ​ (Fig.5). 5 ). The Egger test resulted in a P value of 0.0271, which suggests statistical significance for publication bias. The Trim & Fill method imputed 14 approximated studies, with limited impact of the adjusted results. The change in effect size was from 0.010 to 0.005 with no statistical significance (Fig. ​ (Fig.6 6 ).

Funnel plot.

Funnel plot of the Trim & Fill method.

Sensitivity Analysis

When excluding studies with sample sizes less than 10 and high-risk biased studies, the pooled prevalence was similar 1% (CI <1%–3%) compared with the pooled prevalence when those studies were included 1% (CI <1%–2%).

The prevalence of regret in the TGNB population after GAS was of 1% (CI <1%–2%). The prevalence of regret for transfemenine surgeries was 1% (CI <1%–2%), and the prevalence for transmasculine surgeries was <1% (CI <1%–<1%). Traditionally, the landmark reference of regret prevalence after GAS has been based on the study by Pfäfflin in 1993, who reported a regret rate of 1%–1.5%. In this study, the author estimated the regret prevalence by analyzing two sources: studies from the previous 30 years in the medical literature and the author’s own clinical practice. 20 In the former, the author compiled a total of approximately 1000–1600 transfemenine, and 400–550 transmasculine. In the latter, the author included a total of 196 transfemenine, and 99 transmasculine patients. 20 In 1998, Kuiper et al followed 1100 transgender subjects that underwent GAS using social media and snowball sampling. 23 Ten experienced regret (9 transmasculine and 1 transfemenine). The overall prevalence of regret after GAS in this study was of 0.9%, and 3% for transmasculine and <0.12% for transfemenine. 23 Because these studies were conducted several years ago and were limited to specific countries, these estimations may not be generalizable to the entire TGNB population. However, a clear trend towards low prevalences of regret can be appreciated.

The causes and types of regrets reported in the studies are specified and shown in Table ​ Table5 5 and ​ and6. 6 . Overall, the most common reason for regret was psychosocial circumstances, particularly due to difficulties generated by return to society with the new gender in both social and family enviroments. 23 , 29 , 32 , 33 , 36 , 44 In fact, some patients opted to reverse their gender role to achieve social acceptance, receive better salaries, and preserve relatives and friends relationships. These findings are in line with other studies. Laden et al performed a logistic regression analysis to assess potential risk factors for regret in this population. 46 They found that the two most important risk factors predicting regret were “poor support from the family” and “belonging to the non-core group of transsexuals.” 46 In addition, a study in Italy hypothesized that the high percentage of regret was attributed to social experience when they return after the surgery. 33

Another factor associated with regret (although less prevalent) was poor surgical outcomes. 20 , 23 , 36 Loss of clitoral sensation and postoperative chronic abdominal pain were the most common reported factors associated with surgical outcomes. 14 , 36 In addition, aesthetic outcomes played an important role in regret. Two studies mentioned concerns with aesthetic outcomes. 14 , 47 Only one of them quoted a patient inconformity: “body doesn’t meet the feminine ideal.” 14 Interestingly, Lawrence et al demonstrated in their study that physical results of surgery are by far the most influential in determining satisfaction or regret after GAS than any preoperative factor. 36 Concordantly, previous studies have shown absence of regret if sensation in clitoris and vaginal is achieved and if satisfaction with vaginal width is present. 36

Other factors associated to regret were identified. Blanchard et al in 1989 noted a strong positive correlation between heterosexual preference and postoperative regret. 32 All patients in this study who experienced regret were heterosexual transmen. 32 On the contrary, Lawrence et al in 2003 did not find such correlation and attributed their findings to the increase in social tolerance in North American and Western European societies. 36 Bodlund et al found that clinically evident personality disorder was a negative prognostic factor for regret in patients undergoing GAS. 48 On the other hand, Blanchard et al did not find a correlation among patient’s education, age at surgery, and gender assigned at birth. 32

In the present review, nearly half of the patients experienced major regret (based on Pfäfflin classification), meaning that they underwent or desire de-transition surgery, that will never pass through the same process again, and/or experience increase of gender dysphoria from the new gender. One study found that 10 of 14 patients with regret underwent de-transition surgeries (8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation) for reasons of social regret, true regret or feeling non-binary. 23 On the other hand, based on the Kuiper and Cohen Kettenis’ classification, half of the patients in this review had clear regret and uncertain regret . This means that they freely expressed their regret toward the procedure, but some had role reversal to the former gender and others did not. Interestingly, Pfäfflin concluded that from a clinical standpoint, trangender patients suffered from many forms of minor regrets after GAS, all of which have a temporary course. 20 This is an important consideration meaning that the actual true regret rate will always remain uncertain, as temporarity and types of regret can bring a huge challenge for assessment.

Regret after GAS may result from the ongoing discrimination that afflicts the TGNB population, affecting their freely expression of gender identity and, consequently feeling regretful from having had surgery. 15 Poor social and group support, late-onset gender transition, poor sexual functioning, and mental health problems are factors associated with regret. 15 Hence, assessing all these potential factors preoperatively and controlling them if possible could reduce regret rates even more and increase postoperative patient satisfaction.

Regarding transfemenine surgery, vaginoplasty was the most prevalent. 14 , 19 , 23 , 30 – 33 , 35 , 36 , 44 , 45 Interesintgly, regret rates were higher in vaginoplasties. 14 , 36 , 44 In this study, we estimated that the overall prevalence of regret after vaginoplasty was 2% (from 11 studies reviewed). This result is slightly higher than a metanalysis of 9 studies from 2017 that reported a prevalence of 1%. 13 Moreover, vaginoplasty has shown to increase the quality of life in these patients. 13 Mastectomy was the most prevalent transmasculine surgery. Also, it showed a very low prevalence of regret after mastectomy (<1%). Olson-Kennedy et al demonstrated that chest surgery decreases chest dysphoria in both minors and young adults, which might be the major reason behind our findings. 38

In the current study, we identified a total of 7928 cases from 14 different countries. To the best of our knowledge, this is the largest attempt to compile the information on regret rates in this population. However, limitations such as significant heterogeneity among studies and among instruments used to assess regret rates, and moderate-to-high risk of bias in some studies represent a big barrier for generalization of the results of this study. The lack of validated questionnaires to evaluate regret in this population is a significant limiting factor. In addition, bias can occur because patients might restrain from expressing regrets due to fear of being judged by the interviewer. Moreover, the temporarity of the feeling of regret in some patients and the variable definition of regret may underestimate the real prevalence of “true” regret.

Based on this meta-analysis, the prevalence of regret is 1%. We believe this reflects and corroborates the increased in accuracy of patient selection criteria for GAS. Efforts should be directed toward the individualization of the patient based on their goals and identification of risk factors for regrets. Surgeons should continue to rigorously follow the current Standard of Care guidelines of the World Professional Association for Transgender Health (WATH). 49

CONCLUSIONS

Our study has shown a very low percentage of regret in TGNB population after GAS. We consider that this is a reflection on the improvements in the selection criteria for surgery. However, further studies should be conducted to assess types of regret as well as association with different types of surgical procedure.

Acknowledgments

All the authors have completed the ICMJE uniform disclosure form. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supplementary Material

Published online 19 March 2021

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study

Affiliations.

• 1 From the Department of Plastic and Reconstructive Surgery.
• 2 School of Medicine.
• 3 Department of Obstetrics and Gynecology.
• 4 Department of Urology.
• 5 Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA.
• PMID: 36149983
• DOI: 10.1097/SAP.0000000000003233

Background: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes.

Methods: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared.

Results: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.

Conclusion: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest and sources of funding: none declared.

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• Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Straub JJ, Paul KK, Bothwell LG, Deshazo SJ, Golovko G, Miller MS, Jehle DV. Straub JJ, et al. Cureus. 2024 Apr 2;16(4):e57472. doi: 10.7759/cureus.57472. eCollection 2024 Apr. Cureus. 2024. PMID: 38699117 Free PMC article.
• Pain mechanisms in the transgender individual: a review. Anger JT, Case LK, Baranowski AP, Berger A, Craft RM, Damitz LA, Gabriel R, Harrison T, Kaptein K, Lee S, Murphy AZ, Said E, Smith SA, Thomas DA, Valdés Hernández MDC, Trasvina V, Wesselmann U, Yaksh TL. Anger JT, et al. Front Pain Res (Lausanne). 2024 Mar 27;5:1241015. doi: 10.3389/fpain.2024.1241015. eCollection 2024. Front Pain Res (Lausanne). 2024. PMID: 38601924 Free PMC article. Review.
• Do we urologists know enough about gender minorities with prostate cancer? Javaroni V. Javaroni V. Int Braz J Urol. 2024 Jan-Feb;50(1):87-94. doi: 10.1590/S1677-5538.IBJU.2023.9914. Int Braz J Urol. 2024. PMID: 38166225 Free PMC article. No abstract available.
• Knowledge, Attitudes, and Beliefs of Medical Students Toward Transgender Healthcare: A Community-Driven Initiative. Sengupta T, Soni T, Bolock AM, Heisey SA, Kuchinski EC, Piper BJ, Joyce JM, Carbe CJ. Sengupta T, et al. Cureus. 2023 Dec 5;15(12):e49992. doi: 10.7759/cureus.49992. eCollection 2023 Dec. Cureus. 2023. PMID: 38058529 Free PMC article.
• Suicide-Related Outcomes Following Gender-Affirming Treatment: A Review. Jackson D. Jackson D. Cureus. 2023 Mar 20;15(3):e36425. doi: 10.7759/cureus.36425. eCollection 2023 Mar. Cureus. 2023. PMID: 36950718 Free PMC article. Review.
• Edgerton MT Jr., Langman MW, Schmidt JS, et al. Psychological considerations of gender reassignment surgery. Clin Plast Surg . 1982;9:355–366.
• Van de Grift TC, Elaut E, Cerwenka SC, et al. Surgical satisfaction, quality of life, and their association after gender-affirming surgery: a follow-up study. J Sex Marital Ther . 2018;44:138–148.
• Van de Grift TC, Pigot GLS, Kreukels BPC, et al. Transmen's experienced sexuality and genital gender-affirming surgery: findings from a clinical follow-up study. J Sex Marital Ther . 2019;45:201–205.
• Tucker RP, Testa RJ, Simpson TL, et al. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans. Psychol Med . 2018;48:2329–2336.
• Van der Sluis WB, Bouman MB, de Boer NK, et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med . 2016;13:702–710.
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How I Talk With My Patients About Gender-Affirming Care

A doctor explains how ob-gyns can help with gender transition.

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“I feel really uncomfortable in my body.”

“I don’t ever want to get a period.”

“Please take out my uterus. It doesn’t belong there.”

I often hear such words from people whose gender identity differs from the body they were born in. As an ob-gyn, I can help transgender patients feel and look more like their true selves.

About 2 million adults in the United States are transgender. But many do not fully understand their health care options or how to safely access care. Here’s what I tell my patients about gender-affirming care.

Note: I see patients across the gender spectrum in my practice. This article applies to anyone seeking gender-affirming care, including transmasculine, transfeminine, nonbinary, genderqueer, and gender nonconforming people.

Gender-affirming care is essential health care.

The lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community faces bias in all aspects of society, which can create barriers to health care.

But while our society is still learning to accept the LGBTQ+ community with open arms, transgender people already know who they are. And they have the right to feel comfortable in their own bodies.

When someone’s gender identity is at odds with their appearance and how others view them, they may experience discomfort and distress. This feeling is called gender dysphoria. In severe cases, it can lead to depression, anxiety, and suicidal thoughts. This underscores why gender-affirming care is so essential for those who need it. (It’s important to talk with your doctor about any feelings of depression and anxiety—we can help.)

You have a range of options.

Many people—transgender and otherwise—assume that surgery is an inevitable part of transitioning. In reality, surgery is only one of many ways to help you express your gender identity.

You can choose how you dress and style your hair, as well as the name and pronouns you go by. If you wish to go further, you can turn to an ob-gyn, primary care physician, or other doctor for gender-affirming health care. Options for physically transitioning include:

Hormone therapy: People who are transmasculine can take testosterone to deepen their voice, grow facial hair, and possibly stop periods. People who are transfeminine can take estrogen to help breasts grow and redistribute their body fat.

Chest surgery: People who are transitioning from female to male can have “top surgery” to remove the breasts and reconstruct the chest. Likewise, people who are transitioning from male to female can get breast implants.

Hysterectomy: This surgery removes the uterus and sometimes the surrounding organs. It eliminates periods and the ability to get pregnant. If the cervix is removed, you may no longer need cervical cancer screening.

Genital surgery: “Bottom surgery” is a series of procedures to construct genitals that better match a person’s gender identity.

Health insurance coverage for gender-affirming medications and procedures will depend on where you live and your insurance plan.

There is no one right path.

Gender-affirming care means something different for every transgender person. You can choose to pursue all the steps I’ve outlined, or none of the above. Like all health care, gender-affirming care should be patient-centered and patient-driven . (Note: links may contain gendered language.)

What’s more, your gender transition may evolve over time. You could start with hormone therapy, then seek top surgery years later, and bottom surgery years after that—or never. It all depends on what matters to you.

Take the example of a transmasculine person who wishes to prevent period bleeding and cramps. Many people don’t want to have a hysterectomy, as it is a major surgery with a long recovery time. If having a uterus doesn’t bother them, there are less invasive methods to stop monthly bleeding. Hormone therapy with testosterone can decrease or even stop periods. If testosterone doesn’t fully stop the bleeding, or if they also need birth control, another method such as an intrauterine device (IUD)  could be the way to go.

On the other hand, I’ve had patients who are deeply distressed by their periods, and even the knowledge that they have female organs inside them. A hysterectomy may be the right choice in these individuals, for the sake of their mental health.

You will still need routine care.

Like everyone, transgender people should keep up with routine health care. Experts recommend screening for diseases that affect the organs you still have, even if they don’t align with your gender identity.

For example, anyone with breasts should get mammograms  at the recommended age. If you have a cervix, we’ll want to check for early signs of cervical cancer based on your personal risk and family history. But most people can stop screenings if their breasts or cervix have been surgically removed.

These procedures should take your mental well-being into account. Some transgender people don’t mind getting cervical cancer screening every few years . Others are less comfortable with these screenings. Talk with your doctor about your comfort level. There may be ways to make these screenings easier for you.

Your ob-gyn can also help with:

Birth control: Hormone therapy alone is not a replacement for birth control, even if you no longer get a period. To prevent pregnancy, you can choose a birth control option  that fits your goals and lifestyle.

Having children: Transgender people can still have biological children, so talk with your ob-gyn about your plans for the future. They can help you preserve your fertility before hormone therapy or surgery, and, if you want, help you navigate pregnancy in a way that minimizes gender dysphoria.

Sexual health concerns: From testing for sexually transmitted infections (STIs), to treating pelvic pain  and problems with having sex , your ob-gyn can help you with any questions you may have.

Doctors like me stand ready to help.

You have the right to seek treatment from doctors who are knowledgeable about gender-affirming care . Thankfully, more health care professionals are becoming trained in inclusive care. We are making our practices more welcoming to LGBTQ+ patients, from learning how to prescribe hormone therapy, to helping patients find birth control that fits their gender identity and lifestyle needs.

That said, finding gender-affirming care can be challenging. Laws in some states may limit your doctor’s ability to talk with you about transitioning, much less offer you this care, especially if you are younger than 18. If gender-affirming care is not available where you live, turn to your personal network for referrals. You can also search online. Resources like transcaresite.org are good places to start. If you live far away from the doctor you choose, be sure to ask if they offer virtual visits through video chat or if you’ll need to travel to visit their office.

Life-changing and lifesaving

I’ve had the privilege of providing gender-affirming care for countless transgender patients. This care has looked different for each patient, but they all give feedback that lets me know I’ve helped them. They say things like:

“It’s such a relief.”

“Now I can move on with my life.”

“This who I am. Thank you.”

If you’re considering this type of care, find a health care professional who can help you understand your options and choose what feels right to you. You deserve acceptance, respect, and the chance to express your whole, true self.

Published: May 2023

Last reviewed: May 2023

Copyright 2023 by the American College of Obstetricians and Gynecologists. All rights reserved. Read copyright and permissions information . This information is designed as an educational aid for the public. It offers current information and opinions related to women's health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer .

Dr. Beth Cronin

Dr. Cronin is an obstetrician–gynecologist at Providence Community Health Centers in Rhode Island, as well as a clinical associate professor of obstetrics and gynecology at the Warren Alpert Medical School of Brown University. An advocate of inclusive health care for the LGBTQIA+ community, she also serves as vice chair of the American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women.

What to Read Next

When Making Health Care Decisions, Your Voice Matters

Health Care for Transgender and Nonbinary Teens

What Happens at an Ob-Gyn Checkup and Why? One Doctor Explains.

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

• Patient Care & Health Information
• Diseases & Conditions
• Gender dysphoria

Your health care provider might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. Your provider will also ask about the degree of support you have from family, chosen family and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. It involves feelings of distress due to a strong, pervasive desire to be another gender.

Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Others might instead show symptoms of a mood disorder, anxiety or depression. Or they might experience social or academic problems.

• Care at Mayo Clinic

Our caring team of Mayo Clinic experts can help you with your gender dysphoria-related health concerns Start Here

Treatment can help people who have gender dysphoria explore their gender identity and find the gender role that feels comfortable for them, easing distress. However, treatment should be individualized. What might help one person might not help another.

Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of gender-diverse people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the chest, external genitalia, internal genitalia, facial features and body contour

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair.

Treatments are based on your goals and an evaluation of the risks and benefits of medication use. Treatments may also be based on the presence of any other conditions and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Legal age in a person's country or, if younger, following the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pre-treatment medical evaluation is done by a doctor with experience and expertise in transgender care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments This evaluation may include:

• A personal and family medical history
• A physical exam
• Assessment of the need for age- and sex-appropriate screenings
• Identification and management of tobacco use and drug and alcohol misuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo or ovarian tissue cryopreservation
• Documentation of history of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria.

The goal of behavioral health treatment is to help you feel comfortable with how you express your gender identity, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couples, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of the stress that results from experiencing prejudice and discrimination because of your gender identity (minority stress)
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A behavioral health evaluation may not be required before receiving hormonal and surgical treatment of gender dysphoria, but it can play an important role when making decisions about treatment options. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance misuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

More Information

Gender dysphoria care at Mayo Clinic

• Pubertal blockers
• Feminizing hormone therapy
• Feminizing surgery
• Gender-affirming (transgender) voice therapy and surgery
• Masculinizing hormone therapy
• Masculinizing surgery

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Mental health care. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about any anxiety or depression you're experiencing.
• Support groups. Talking to other transgender or gender-diverse people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritizing self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditation or prayer. You might find comfort and support in your spirituality or faith communities.
• Getting involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for your appointment

You may start by seeing your primary care provider. Or you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms , including any that seem unrelated to the reason for your appointment
• Key personal information , including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your health care provider
• Ferrando CA. Comprehensive Care of the Transgender Patient. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Hana T, et al. Transgender health in medical education. Bulletin of the World Health Organization. 2021; doi:10.2471/BLT.19.249086.
• Kliegman RM, et al. Gender and sexual identity. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Ferri FF. Transgender and gender diverse patients, primary care. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Nov. 8, 2021.
• Keuroghlian AS, et al., eds. Nonmedical, nonsurgical gender affirmation. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Nov. 8, 2021.
• Coleman E, et al. Surgery. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Version 7. World Professional Association for Transgender Health; 2012. https://www.wpath.org/publications/soc. Accessed Nov. 3, 2021.

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Aiming for Equitable Care for Transgender Patients

• Vanessa Caceres

At the same time, survey results presented at SHM Converge in 2021 found that 51% of 259 respondents did not feel clinically competent in providing care to transgender patients and 78% wanted to learn more about LGBTQIA+ healthcare. 1

The 2022 U.S. Transgender survey from the National Center for Transgender Equality, which included more than 92,000 transgender people, found that among those who had seen a healthcare practitioner in the previous 12 months, 48% had at least one negative experience because they were transgender. This included being refused healthcare, being misgendered, having a clinician use harsh language with them, or having a practitioner be physically rough or abusive when treating them. 2

Among those with health insurance in the survey, 26% had at least one issue with their insurance company in the previous year, such as being denied coverage for hormone therapy, surgery, or another type of healthcare issue linked to their gender identity or transition.2

Challenges for equitable care

Oklahoma, South Carolina, Missouri, and Tennessee are the four states with the largest number of anti-trans bills under consideration this year, according to the website Trans Legislation Tracker. In Oklahoma alone, 60 anti-trans bills had been introduced as of mid-April. 3

The number of anti-trans bills across the U.S. has increased rapidly since 2021; in that year, 143 bills were introduced and 18 passed. By 2023, 600 bills were introduced around the U.S., and 87 passed. Pertinent legislation around the U.S. relates to topics such as diversity, equity, and inclusion (DEI); trans individuals participating in sports; teaching about LGBTQIA+ youth; and other topics. 

Laura Bishop, MD (she/her), an associate professor in internal medicine and pediatrics and the med-peds associate program director at the University of Louisville in Kentucky, has observed that out of fear, some patients have been less inclined to disclose their gender identities to treatment teams or their families. Among young patients, changes to gender-affirming care in Kentucky have led to an abrupt discontinuation of hormones. This also has led to an increase in mental health crises among patients who are already impacted by financial insecurities and are not typically able to travel to other states for care.

This fear trickles down to other members of the LGBTQIA+ community.

The anti-trans legislative climate in many states creates a catch-22, says Anthony Dao, MD (he/him), an assistant professor of medicine at Washington University School of Medicine in St. Louis, Mo., and director of OUTmed, a group for LGBTQIA+ trainees, faculty, and staff at WashUMed. Anti-trans or anti-LGBTQIA+ legislation may lead people in these population groups to move elsewhere. At the same time, this lessens overall diversity, perhaps continuing to limit views from others.

“I don’t know a single queer person who hasn’t thought about leaving Missouri,” said Dr. Dao, who is gay. “Part of my decision to stay was knowing that I’ve committed to creating a difference for my community. Things won’t be better in Missouri if I leave. Each person in our community matters.” Restrictions to the practice of evidence-based medicine have repercussions that go further than intended, says Dr. Bishop, a point that she has shared in recent talks with legislators. “When pediatric endocrinologists are less inclined to train in a state that restricts their full practice, it affects many more patients than those who are transgender,” she said.

Dr. Khanijow

Although many hospitalists may want to learn more about transgender care, there’s also a lack of sufficient education. This can turn into “transgender broken arm syndrome,” said Keshav Khanijow, MD (he/him), who’s an assistant professor at the Johns Hopkins University School of Medicine in Baltimore, and chair of the SHM Diversity, Equity, Inclusion, and Justice Special Interest Group. “One pitfall for clinicians is becoming overwhelmed and hyper-concentrated on a patient’s transgender identity because of their presenting concern and misattributing causes of their hospitalization to gender-affirming hormones as opposed to other reasons,” he said.

Another pitfall Dr. Khanijow has seen is the use of the wrong terms when referring to trans patients, such as “transsexual,” “gender reassignment” surgery or hormones, and “a transgender,” which can be offensive.

“Unfortunately, ICD-10 codes may not have caught up to this and still use some of this offensive terminology in coding,” said Dr. Khanijow, who is also a member of the SHM Diversity, Equity, and Inclusion Committee.

Appropriate terminology would be what the patient states their gender identity is, though commonly “the patient is a trans woman” (or man) is okay, Dr. Dao says. Another example is “The patient identifies as a non-binary individual and uses they/them pronouns.”

Similarly, electronic health records (EHRs) may not have caught up with appropriate terminology and may not have a clear, consistent way to collect pronouns. This means that trans patients may be asked repeatedly for their pronouns, Dr. Dao says.

Deficiencies in education about transgender health basics are common among even well-meaning practitioners, particularly those who graduated before 2015, says Masina Wright, MD (they/themme), a locum hospitalist in New Mexico. “Let’s take perioperative medicine, for example,” they said. “For those practicing hospital medicine, have you ever taken a CME course on perioperative management of a transgender woman on gender-affirming hormones? What does the evidence say? Is this discussed in Grand Rounds at your hospital?”

Improving transgender care at the administrative level

Although equitable care for transgender patients faces obstacles, there are still initiatives that hospitalists can take to improve care. Here are some strategies to implement at the administrative level.

Aim for a diverse clinical team . “Administrators are high-level people who care about various perspectives and care for different patients. They should be thoughtful in curating their team to have various opinions and diversity,” Dr. Dao said. Having various perspectives increases the chance that someone on the team will be thinking about building trust with different groups of people, including transgender patients.

Advocate for more education about transgender care and LGBTQIA+ care in general. This education can take place at the hospital level (including asking about pronouns) as well as at conferences. SHM has modules on its learning portal that are updated with appropriate documentation and recommended language, and it released a module on transgender healthcare in 2021, Dr. Khanijow says. On a more global level, the World Professional Association for Transgender Health will take place this September in Portugal, Dr. Wright says. There’s also a U.S. Professional Association for Transgender Health every other year, with the last one held in 2023. However, Dr. Wright would like to see trans health integrated into a variety of conferences so it becomes normalized. “Once the appropriate language and basic foundational understanding of gender diversity become just a regular part of the human experience, trans folks can be seen like every other human in the medical system—depoliticized,” they said.

Use EHRs that allow staff to easily list pronouns and remind staff to list those pronouns. “An EHR that easily identifies pronouns/names and actually prints them to a daily list can prevent damaging misgendering or dead-naming,” Dr. Bishop said. Dead-naming is the use of a name given to someone at birth that they no longer use due to a gender transition.

Participate in DEI committees. This can assist with better care for transgender as well as all other patients. “Hospitalists should collaborate with members of their DEI committees,” Dr. Dao said. “Many DEI committees feel like the ‘minorities’ are there to teach the majority. The truth is that all hospitalists are responsible for the advancement of all people.” 

Be a leader and set the tone. “In hospital medicine, a lot of the care is driven by the hospitalist,” Dr. Dao said. “You really set the tone for your team when you’re there. When you have a trans patient, as the leader of the time, you’re setting that positive tone for the patient and making sure [fellow staff] know that the patient is trans and has preferred pronouns.” He also reminds staff of the importance of not misgendering the patient or unnecessarily exposing them. If they have questions about the patient, they can ask a team member or review the chart rather than asking the patient. “Creating a safe environment for your staff to ask you questions has allowed me to have meaningful conversations with my nurses and staff, especially because most intent is that of curiosity rather than of harm,” he said. “Sometimes, it may involve focusing on what everyone can do to best help the patient move forward with their chief health concern.”

Improving transgender care at the patient level

There are also specific approaches and strategies that hospitalists can take directly with transgender patients to improve their care:

Focus on their chief health concern . Avoid “transgender broken arm syndrome,” Dr. Khanijow cautions.

Aim for equitable care, not just equal care , Dr. Khanijow advises. Because of the prejudice faced by transgender patients, this may mean taking extra steps to keep these patients safe and comfortable, such as receiving a private room or a room with someone of the same gender identity and setting up reasonable post-discharge follow-up with clinics known for culturally competent care. This also can mean supporting the patient’s identity while they are at the hospital with the use of makeup, prostheses, clothing, or jewelry of their choice. Although hospitalists are bound by local laws, they still can empathize with the patient about how unfair a legal situation might be and try to come up with creative solutions to help patients achieve their goals despite a hostile legal environment, Dr. Khanijow says.

Acknowledge their partners . It’s typical for providers to ask patients if they have a partner to be inclusive, but also be aware that patients may sometimes refer to their partners as their “friends,” Dr. Dao said. “While it’s unnecessary to bully your patient into telling you who is actually with them, it’s important to take a moment and thank them for being there for the patient,” he said. This also includes asking partners what their pronouns are or asking the patient if they can share their partner’s pronouns.

Encourage the use of gender-affirming hormones, PrEP, or other related medications unless there’s a clear contraindication, Dr. Dao says. This is yet another area that’s ripe for more education geared toward hospitalists and other providers. In the 2022 U.S. Transgender Survey, 98% of respondents receiving hormone treatment reported that hormones for their gender identity or transition made them a lot more satisfied (84%) or a little more satisfied (14%) with their life. 

Vanessa Caceres is a medical writer in Bradenton, Fla. 

• Khanijow K, Rosendale N, et al. Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health: The Q-Health Project: Abstract 40 published at SHM Converge 2021. Society of Hospital Medicine website. https://shmabstracts.org/abstract/quantifying-hospitalist-education-and-awareness-of-lgbtq-topics-in-health-the-q-health-project/ . Accessed April 23, 2024.
• James SE, Herman JL, et al. Early Insights: A Report of the 2022 Transgender Survey. Washington, DC: National Center for Transgender Equality; 2024. Available at: https://transequality.org/sites/default/files/2024-02/2022%20USTS%20Early%20Insights%20Report_FINAL.pdf . Accessed April 23, 2024.
• Oklahoma. Trans Legislation Tracker website. https://translegislation.com/bills/2024/OK . Accessed April 23, 2024.

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The Biden Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA

Lindsey Dawson , Laurie Sobel , Kaye Pestaina , Jennifer Kates , Samantha Artiga , and Alice Burns Published: May 15, 2024

This brief provides an overview of the Biden Administration 2024 final rule implementing Section 1557 of the ACA, which is home to the law’s major nondiscrimination provisions. While Section 1557’s protections took effect when the ACA was enacted in 2010, much of its reach has been determined by implementation guidance issued across different Presidential administrations, often reflecting conflicting views. The final rule reinstates and expands upon many of the 2016 regulations from the Obama Administration and is a reversal from much of the 2020 Trump Administration rule. We provide a brief background on 1557 rulemaking and identify key differences between this rule and the 2020 rule. We also highlight two areas of growing interest impacted by the rule – nondiscrimination protections for pregnancy related decisions, past, present and future, including abortion, and for transgender people. Despite the issuance of the final rule, debates about 1557’s protections, and ensuing litigation, continue and will be particularly dependent on the outcome of the 2024 Presidential election.

Introduction

On April 27, 2024, the Biden Administration’s Department of Health and Human Services (HHS) finalized long-awaited revised regulations implementing Section 1557 of the Affordable Care Act (ACA). Section 1557 prohibits discrimination on the basis of race, color, national origin, age, disability, or sex and applies to health programs and activities receiving federal financial assistance (referred to as covered entities). In broad terms, it prevents covered entities from discriminating against certain protected groups in providing health care services, insurance coverage and program participation. The rule has staggered effective dates starting on July 5, 2024. In broad terms, 1557 provides nondiscrimination health care protections to individuals in protected groups, including prohibiting denial of benefits, coverage, program participation, and otherwise unequal treatment based on these factors

The administration also released a FAQ and press release . Section 1557 houses the law’s major nondiscrimination provisions by incorporating protections from existing civil rights laws. These laws include Title VI of the Civil Rights Act of 1964 (race, color, and national origin), Title IX of the Education Amendments of 1972 (sex), the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973 (disability). Notably, Section 1557 is the first federal civil rights law to prohibit discrimination on the basis of sex in health care.

Section 1557’s protections took effect when the ACA was enacted on March 23, 2010, but much of the law’s reach has been determined by implementation guidance issued by different Presidential administrations, reflecting different interpretations  and  priorities. Across the Obama, Trump, and Biden administrations, the 1557 implementing regulations have volleyed back and forth in their interpretations, particularly related to the scope of entities covered by the law and the law’s ability to provide nondiscrimination protections based on sexual orientation and gender identity and pregnancy related conditions. These debates, and ensuing litigation, are likely to continue, and will be particularly dependent on the outcome of the 2024 Presidential election.

Most of the implementing regulations in the new rule are effective 60 days (July 5, 2024) after publication in the Federal Register (May 6. 2024). Some provisions impacting health insurance plan design won’t become effective until the plan year beginning after January 1, 2025, and other provisions where entities might need additional time to amend current practices also have later effective dates. (The rule and the FAQ provide a table of these dates.)

The FAQ accompanying the rule states it was necessary to issue this guidance “to restore and strengthen civil rights protections for individuals consistent with…the statutory text,” noting that the 2020 Trump Administration rule “covers fewer programs and services and limited nondiscrimination protections for individuals.”

Section 1557 has been subject to a wave of litigation across administrations. Litigation has both centered on rulemaking and on the statue itself. In some cases (e.g. Franciscan Alliance v. Azar ), courts have found narrowly in favor of plaintiffs who have asserted that the requirement to cover or provide certain services, such as those related to termination of pregnancy or gender affirming care, violated their sincerely held religious beliefs and thus religious freedom protections. In other cases, courts have found that Section 1557 protects access to these same services, such as by requiring state Medicaid programs to cover gender affirming care (e.g. Flack v. Wisconsin ). Courts have also weighed in on the legality of aspects of rulemaking (e.g. Whitman-Walker Clinic v. HHS ) and litigation has already been filed in the state of Florida by the attorney general and a Catholic hospital group challenging the new rule (see State of Florida et al v. HHS et al . )  In addition, litigation related to other civil rights protections ( Bostock v Clayton County, Georgia) has implications for Section 1557 and, in particular, this regulation’s interpretation of nondiscrimination based on sex. (Box 1)

Box 1: Impact of Bostock v Clayton County, Georgia on Section 1557

In June 2020, just three days after the Trump Administration rule was finalized, the Supreme Court ruled in  Bostock v Clayton County, Georgia that in the context of employment, discrimination based on sex encompasses sexual orientation and gender identity. The Bostock ruling does not directly apply to 1557 because it was based on interpretation of sex protections under Title VII and the 1557 sex protections are pulled in through Title IX. However, courts have historically looked to Title VII in interpreting Title IX, including in cases where plaintiffs challenged the Trump-era rule. As such, prior to issuing the new regulation , the Biden Administration issued guidance in May 2021 stating it would interpret and enforce 1557’s sex nondiscrimination provisions to include protections on the basis of sexual orientation and gender identity in light of and consistent with Bostock .

Summary of Major Changes

The final rule closely mirrors a proposed rule  issued by the Biden administration in July of 2022 and is, in many ways, a reversal of the final rule issued by the Trump Administration in June of 2020, which itself was a significant departure from the Obama Administration regulations issued in 2016. This  final  rule reinstates and expands upon much of those 2016 regulations. Compared to the previous rules, key changes in the Biden Administration final rule include:

• Section 1557 applies to health programs or activities that receive direct or indirect federal financial assistance from HHS, health programs and activities administered by HHS, and Therefore, covered entities include state Medicaid agencies, Medicare, many health insurance plans, and most hospitals and providers, among others. The new rule expands on the types of entities subject to 1557 compared to the Trump rule, including by determining that 1557 protections apply to products sold by issuers with plans on the marketplaces (not just the marketplace plans themselves) and by considering Medicare Part B as receiving Federal financial assistance for the first time;
• Provides nondiscrimination protections for those who experience discrimination on the basis of multiple protected characteristics. (A new protection compared to both the Obama and Trump rules);
• Explicitly provides for nondiscrimination protections based on gender identity and sexual orientation, sex characteristics (including intersex traits), and pregnancy related conditions including pregnancy termination, as well as related specific health insurance coverage protections, expanding these moderately compared to the Obama rule and completely compared to the Trump rule;
• Provides specific nondiscrimination protections for transgender people’s access to care and coverage, expanding moderately on those in the Obama rule and completely compared to the Trump rule. The rule requires people be treated consistently with their gender identity, prohibits the denial of gender affirming care when provided for other purposes, if the denial is on the basis of sex, and the categorical exclusion of gender affirming care. (See box 3 for additional details related to this provision);
• Protects patients from discrimination on the basis of actual or perceived abortions but states it is not a violation of Section 1557 if providers do not provide abortions unless the provider does not do so based on an individual’s protected status (e.g. race, age, etc.) (See box 2 for additional details related to this provision);
• Removes explicit blanket abortion and religious freedom exemptions which the Trump rule incorporated through Title IX’s religious exemptions, stating instead that robust religious freedom protections exist outside of Section 1557 and that incorporation of Title IX exemptions through the rule is not necessary;
• Adopts a new religious freedom and conscience protections exemptions process;
• The new rule reinstates explicit prohibitions on discrimination based on gender identity and sexual orientation that had existed in ten other federal regulations outside Section 1557. The protections were put in place through Obama Administration regulations and related to coverage, access, and marketing, in Medicaid, private insurance, and the Marketplaces but were eliminated in the Trump Administration’s 1557 rule.;
• Expands protections for those with limited English proficiency (including in telehealth) compared to both prior rules;
• Includes new provisions for services requirements and notices related to language access and access to auxiliary aids and services, and adopts new policies and staffing requirements for 1557 compliance;
• Reaffirms most requirements related to disability discrimination from the 2016 rule, which complement a new rule on web accessibility for public entities under the Americans with Disabilities Act and major updates to regulations implementing Section 504 of the Rehabilitation Act, which were last updated in 1977. Section 504 prohibits recipients of federal funding, including publicly-subsidized health payers and health care providers who accept Medicare or Medicaid, from discriminating against people on the basis of disability. Among other changes, the Section 504 health provisions address discrimination in medical treatment, create enforceable standards for medical equipment, address accessible web content and mobile apps, and codify the Olmstead requirement to serve people with disabilities in the most integrated setting that is appropriate.
• Reflecting emerging technologies, for the first time, addresses and applies Section 1557 nondiscrimination protections to the use of telehealth and patient care decision support tools, including in addressing bias in clinical algorithms and other tools and in the use of AI.

Box 2: Abortion – Protections from Sex Discrimination Includes Pregnancy Termination

The ACA protects providers and programs based on their willingness to provide, pay for, cover, or refer for abortion or to provide or participate in such trainings. The new final Section 1557 rule includes protections for patients on discrimination on the basis of having had actual or perceived abortions. OCR explains that a covered provider’s decision not to provide an abortion is not a violation of Section 1557 unless the provider chooses not to provide abortion for a particular individual based on a protected ground such as race. Some commenters “expressed concern that Dobbs created tension between health providers, and patients, increasing distrust in providers and that it has created chaos in the health care system. They state this has increased the risk that patients will experience discriminatory care and suffer delays in lifesaving treatment as a direct result of legal and medical uncertainty. These commenters said that discrimination in care propagates more distrust, which is a significant barrier for individuals seeking care and is precisely what section 1557 was designed to protect against.” OCR responded to these concerns noting that it is considering revisions to the HIPAA Privacy Rule to strengthen privacy protections for individuals’ protected health information related to reproductive health care.

Box 3: Care and Access for Transgender People – Protections from Sex Discrimination Include Gender Identity

Section 1557’s regulatory treatment of sexual orientation and gender identity has changed considerably over time. The 2016 Obama Administration rule interpreted sex nondiscrimination protections to include gender identity and sex stereotyping (among other identities) but not sexual orientation. At that time, HHS stated it would “evaluate complaints alleging sex discrimination … sexual orientation” on a case-by-case basis and anticipated that case law would evolve as to clarify whether sexual orientation could be covered. The Trump Administration did not define sex in the regulatory text but in the preamble suggested it would interpret sex to mean only biological sex assigned at birth. The Biden Administration interpreted sex to include sexual orientation and gender identity (among other identities), reaffirming its earlier guidance which took the same approach, in light of Bostock (see Box 1). It also extends these protections to include intersex people for the first time.

As noted above, the new rule also reinstates explicit prohibitions on discrimination based on gender identity and sexual orientation in regulations outside of Section 1557 that had been put in by the Obama Administration but eliminated through the Trump Administration’s 1557 rule.

In addition, the rule, in text and preamble, spells out specific protections for transgender people and access to gender affirming care including that entities cannot refuse gender affirming care services that would be provided to an individual for other purposes, if the limitation is based on sex or gender and that the categorical exclusions of gender affirming care is prohibited. It does not prohibit nondiscriminatory denial of services with the preamble noting “OCR has a general practice of deferring to a clinician’s judgment about whether a particular service is medically appropriate for an individual, or whether the clinician has the appropriate expertise.” OCR states any investigations will not focus on clinical judgment per se but rather whether that judgment reflects unlawful bias, The rule also does not prevent a covered entity from availing itself of religious freedom and creates new pathways for asserting such protections. (Additional details in Table 1.)

Some commenters had specific concerns regarding the rule’s application to “State laws that prohibit access to gender-affirming care…” OCR responded that “some States may have laws…that are contrary to the final rule’s nondiscrimination protections, and…section 1557 preempts those laws.” The conflict between state and federal law in this case is unresolved and the Florida Attorney General, along with a Catholic medical group, has filed suit alleging that the rule requires providers to provide gender affirming care and violates protections.

Table 2 summarizes the major provisions of HHS’s new final rule and provides a side-by-side comparison to the Obama (2016) and Trump (2020) administration rules.

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• KFF Examines New Rule Giving LGBTQ+ People More Protections Against Discrimination in Health Care

Also of Interest

• LGBTQ Health Policy
• The Trump Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA and Current Status
• Summary of HHS’s Final Rule on Nondiscrimination in Health Programs and Activities

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A.G. File No. 2023-020

Pursuant to Elections Code Section 9005, we have reviewed the proposed measure (A.G. File No. 23-0020, Amendment #1) related to certain gender-affirming medical procedures for individuals under the age of 18 years.

Some Children Are Transgender. Sex generally refers to a person being biologically male, female, or intersex. The attitudes, feelings, and behaviors that a given culture associates with these biological designations are generally known as gender. Gender identity generally refers to an individual’s internal sense of being male, female, or something else. For example, transgender individuals have gender identities that differ from the sex assigned to them at birth.

Transgender Children Are a Small Share of California’s Population. Data on transgender individuals are limited. That said, research suggests that transgender individuals comprise a small share of children. For example, one recent study by the Williams Institute at the University of California, Los Angeles estimates that nearly 50,000 individuals (around 2 percent) of individuals between the age of 13 to 17 years identify as transgender in California.

Some Transgender Children Receive Health Care Services to Affirm Their Gender Identity. Some transgender individuals experience distress from having a gender identity that is different from their sex assigned to them at birth. Transgender individuals experiencing distress can receive certain health care services, including mental health services and medical treatments. These treatments can be a part of what is referred to as “gender affirming care.” Medical treatments can include prescription drugs to postpone the development of puberty (known as “puberty blockers”), hormone therapies, and surgeries. For transgender children, decisions around which treatment to provide and when to provide the treatment are made jointly by the physician and parent of the child, generally following professionally recognized standards.

California Law Protects Access to Gender-Affirming Care. A number of laws in California protect access to gender-affirming care for transgender individuals. For example, California law prohibits health insurance plans from discriminating against transgender patients, including by denying patients access to gender-affirming treatments when the treatments are medically necessary.

California Helps Pay for Health Care for Many Individuals, Including Gender Affirming Care. State and local governments help certain Californians pay for health care through a number of different programs. For example, Medicaid, known as “Medi-Cal” in California, provides health coverage to eligible low-income California residents. It is funded from a mix of federal, state, and local funds. Health care services covered by Medi-Cal include gender affirming care for transgender individuals, generally when considered to be medically necessary.

California Licenses Health Care Providers. California law requires health insurance plans, health care providers, and health care facilities to be licensed to provide health care services. Several departments are responsible for licensing health care entities in California. For example, the Department of Consumer Affairs includes numerous licensing boards that license health care providers, such as physicians, nurses, and pharmacists, among others. These departments and boards generally cover the cost to license providers and investigate complaints by charging affected providers fees and fines.

Prohibits Providing Certain Medical Treatments That Affirm a Different Gender Than Biological Sex for Youth. The measure would prohibit health care providers (such as a physician or a nurse) from providing patients under the age of 18 certain medical treatments that affirm a gender identity different than the patient’s biological sex. The initiative specifically would prohibit prescribing or administering puberty blockers, hormones or hormone antagonists, and surgery or medical procedures. The measure defines biological sex as either male or female, based on specified physiological and genetic attributes.

Excludes Three Kinds of Services From Prohibitions. The measure would exclude from these prohibitions the following: (1) services medically necessary to treat a minor born with a medically verifiable genetic disorder of sexual development; (2) services to return a child who previously received gender-affirming procedures back to his or her biological sex; and (3) services to children who began gender-affirming procedures prior to when the measure becomes law or January 1, 2025, whichever is earlier.

Enacts Consequences to Providers for Providing Services. Except for the exclusions described in the previous paragraph, providing a prohibited medical service under the measure would be considered unprofessional conduct and subject to discipline and a hearing process by the provider’s licensing entity. The measure specifies that such discipline would include revoking of the health care provider’s license or certification.

Fiscal Effect

Impact Depends on Court Rulings Related to Gender-Affirming Health Care. In recent years, several states have enacted prohibitions on health care providers from providing certain gender-affirming medical treatments, including treatments that would be prohibited under this measure. Many of these laws are being litigated in the federal court system to determine whether they conflict with the United States Constitution. At the time of this analysis, the courts have allowed bans in some states to take effect, while bans in other states have not been allowed to go into effect. If a court were to rule this measure could not go into effect, it would have no fiscal effect. Alternatively, were the measure to withstand legal challenges, there would be fiscal effects, described below.

If Measure Becomes Law, Possible Minor Savings From No Longer Covering Prohibited Treatments… Were the measure to become law, state and local government health programs that pay for gender-affirming puberty blockers, hormone therapies, and surgeries for youth could no longer do so. Although comprehensive data on state and local government spending for these services is not available, it could be as much as in the millions of dollars annually. This represents a very small share of overall state and local spending, with the state General Fund providing $37.5 billion to Medi-Cal in 2023-24, for example.

…Could Be Impacted by Other Long-Term Effects. The savings from no longer paying for health care services could be increased, reduced, or even offset by other health-related impacts. For example, some Medi-Cal enrollees under the age of 18 who otherwise would have received prohibited services may choose to receive some of these services when they are adults. In these cases, some of the spending associated with prohibited services would still occur, but at a later time for the individual. In other cases, individuals who are eligible for Medi-Cal as children may earn too much income to qualify for Medi-Cal as adults or forgo these services altogether. These effects are difficult to project. Also adding to the fiscal uncertainty, the long-term effects on mental and physical health of providing gender-affirming care to transgender youth are actively being studied. Depending on these long-term impacts, prohibiting certain gender-affirming medical treatments on individuals under the age of 18 could affect the use of health care services, with corresponding fiscal impacts

Potential, but Unknown, Cost Pressure Related to Federal Anti-Discrimination Laws. Federal law prohibits health care providers that receive federal funding for health programs (such as Medicaid) from discriminating against patients on the basis of race, sex, and other factors. Federal courts currently are assessing whether these nondiscrimination provisions extend to gender identity and the provision of gender-affirming care. Depending on the decisions in these court cases and any resulting federal actions, California providers could face a number of potential consequences, including revoked federal funding. Such actions also could place pressure on state and local governments to backfill lost federal funding. Whether action is taken and the magnitude of such action is unknown, but the impact could be significant.

Summary of Fiscal Effects. We estimate the measure would have the following fiscal effects:

• To the extent the measure can be legally implemented, potentially relatively minor savings up to the millions of dollars annually from no longer paying for prohibited services for individuals under the age of 18. These savings could be affected by many other impacts, such as individuals seeking treatment later in life.
• Potential, but unknown, cost pressure to state and local governments related to federal fiscal penalties if the measure results in providers being deemed out of compliance with federal law.