by Grace Gibson

Graphic design by Qingyue Guo

Recognition of transgender and gender diverse (TGD) people—individuals whose gender identity does not align with their sex assigned at birth—has greatly increased over the past decade. Correspondingly, as more people have come to identify as transgender and gender non-conforming, the medical field has seen increased demand for gender-affirming healthcare—medical treatments that contribute to a patient’s gender transition.¹ Despite these interventions being medically necessary for many patients,² the politicization of transgender healthcare and the growing movement of anti-trans legislation throughout North America threatens their accessibility to patients in need.^3,4 Promoting access to gender-affirming care helps TGD people, an already underserved group, avoid further marginalization in seeking healthcare.

Gender-affirming care, also called transition-related care, consists of medical interventions like hormone replacement therapy (HRT) and gender-affirming surgery (GAS) that enables a patient’s physical traits to more closely align with their gender identity.⁵ This often reduces gender dysphoria, a state of distress or discomfort caused by the incongruence between one’s gender identity and physical characteristics.⁶ While every person’s transition is unique, many TGD people seek out one or more forms of GAS as part of their transition-related care.⁷ Though the popularity and visibility of transition-related surgeries have increased in recent years,¹ these surgeries are not as new or experimental as they may seem. Many modern forms of GAS—including orchiectomy (removal of the testes), penectomy (removal of the penis), and vaginoplasty (construction of a vagina)—originated in the early 20th century with the work of surgeon Magnus Hirschfeld at the Institute for Sexual Research in Berlin, Germany.^1,9 While historical understandings of gender identity differed widely from modern standards, patients undergoing GAS at the time reported therapeutic benefits from receiving these surgeries, and outcomes only improved throughout the mid-20th century as surgeons refined and shared their techniques.¹ Modern surgeons established current practices of GAS from over a century of development in surgical techniques, making many transition-related surgeries older than procedures like coronary artery bypass (first performed in 1960),¹⁰ heart transplantation (1967),¹¹ and total knee replacement (1966-68).¹²

From the earliest days of GAS, the primary goal of surgery was to align a patient’s physical traits with their gender identity; however, secondary outcomes go beyond a simple resolution of this incongruence. Though some of these procedures may be labelled as cosmetic, there is significant evidence that receiving GAS is medically necessary and even life-saving for TGD patients.² Postoperative GAS patients experience significant clinical benefits, including improved body image, fewer hospitalizations related to mental health emergencies, reduced suicidal ideation and suicide attempts, and even reduced tobacco use.¹³ These improvements persist in both the short and long term.^13,14 There is further evidence that even when patients experience complications or dissatisfaction with their surgical outcomes, few express regret for having received GAS—overall regret rates for all gender-affirming procedures are reported between one and two percent according to recent reviews.^13,15,16 Gender-affirming procedures appear to offer their recipients significant improvements without equivalent drawbacks that induce postoperative regret. 

Due to these factors, access to transition-related care is crucial for the well-being of TGD patients. Despite this, many TGD people face significant barriers to receiving healthcare, whether transition-related or not. Many healthcare providers are undereducated about the needs of TGD patients, limiting their ability to provide culturally competent care that addresses the specific challenges that these patients experience.^17,18 Some TGD people report facing discrimination or harassment from medical professionals, and even those who encounter sympathetic clinicians often find they are unaware of the healthcare needs of TGD patients, placing a burden on the patients to educate their providers.¹⁸ Beyond these barriers to accessing medical care, pursuing GAS comes with its own challenges, including outdated methods for assessing eligibility for GAS and few surgeons specializing in these procedures.^2,17

Due to a rise in politically motivated transphobia, legislation aiming to limit transition-related healthcare has become prevalent throughout the United States (US) and United Kingdom (UK), with similar legislation being introduced in some regions of Canada.^3,4,20 Such social and political opposition to gender-affirming healthcare is not new. In an extreme example, Nazi book burnings in the 1930s targeted Magnus Hirschfeld’s Institute for Sexual Research, where many advancements in modern GAS originated.¹ For several decades following this destruction of research and medical advancement, the amount of surgeons practicing GAS remained scarce because of societal and political opposition to this kind of medical care.¹ Public perceptions and awareness of TGD people have shifted since the mid-1900s; however, recent years have seen a rise in misinformation about transgender healthcare and a surge in transphobia, leading to extensive legislation banning or limiting certain forms of gender-affirming care.^3,4,19 Throughout the US, lawmakers introduced 120 anti-trans bills—many of which restricted transgender healthcare—in November and December 2024 alone,¹⁹ while in the UK, extensive anti-trans legislation has limited access to and even criminalized transition-related care in some circumstances.³ In Canada, federal protections for TGD people are currently robust, but 2024 legislation in Alberta proposed a complete ban on transition-related hormone therapy under the age of 16 and GAS under the age of 18, prompting some fears that Canadian federal lawmakers may follow the anti-trans example set by the US and UK in the future.²⁰ Compounded upon existing healthcare barriers and inequities, this legislation further threatens the ability of TGD people to receive gender-affirming care, including GAS.

The inequity and discrimination faced by TGD people reveal a need for improved understanding of TGD patient experiences among medical professionals, a greater effort to promote access to effective interventions like GAS, and a stronger advocacy movement for the rights of TGD people. While GAS may seem like a niche sub-specialty within the medical field, achieving healthcare equity means ensuring that all patients, regardless of their identity or background, can access the medical care they require. 

References

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Oles N, Fontenele R, Abi Zeid Daou M. Transgender History, Part II: A Brief History of Medical and Surgical Gender-Affirming Care. Behav Sci Law. 2025 Jul-Aug;43(4):351-356. 

Tanenbaum GJ, Holden LR. A Review of Patient Experiences and Provider Education to Improve Transgender Health Inequities in the USA. Int J Environ Res Public Health. 2023 Oct 20;20(20):6949. 

Connolly DJ, Meads C, Wurm A, et al. Transphobia in the United Kingdom: a public health crisis. Int J Equity Health. 2025 May 28;24(1):155.

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Joseph A, Cliffe C, Hillyard M, et al. Gender identity and the management of the transgender patient: a guide for non-specialists. J R Soc Med. 2017 Apr;110(4):144-152. 

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Arteaga R, Dryden K, Blasdel G. Patient education and surgical decision-making in genital gender-affirming surgery. Curr Opin Urol. 2024 Sep 1;34(5):308-313.

Selvaggi G, Salgado CJ, Monstrey S, et al. Gender Affirmation Surgery. Biomed Res Int. 2018 Jul 5;2018:1768414. 

Zilavy AJ, Santucci RA, Gallegos MA. The History of Gender-Affirming Vaginoplasty Technique. Urology. 2022 Jul;165:366-372. 

Rocha EAV. Fifty Years of Coronary Artery Bypass Graft Surgery. Braz J Cardiovasc Surg. 2017 Jul-Aug;32(4):II-III. 

Cooper DKC. Christiaan Barnard-The surgeon who dared: The story of the first human-to-human heart transplant. Glob Cardiol Sci Pract. 2018 Jun 30;2018(2):11. 

Albana MF, Scuderi GR, Tria Jr AJ. The Evolution of Total Knee Replacements. In: The Cruciate Ligaments in Total Knee Arthroplasty. Cham: Springer Nature Switzerland; 2024. p. 3–15.

Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021 Jul 1;156(7):611-618. 

Park RH, Liu YT, Samuel A, et al. Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study. Ann Plast Surg. 2022 Oct 1;89(4):431-436. 

Ren T, Galenchik-Chan A, Erlichman Z, et al. Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review. Ann Plast Surg. 2024 May 1;92(5):597-602.

Bustos VP, Bustos SS, Mascaro A, et al. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plast Reconstr Surg Glob Open. 2021 Mar 19;9(3):e3477. 

Hostetter CR, Call J, Gerke DR, et al. “We Are Doing the Absolute Most That We Can, and No One Is Listening”: Barriers and Facilitators to Health Literacy within Transgender and Nonbinary Communities. Int J Environ Res Public Health. 2022 Jan 22;19(3):1229. 

Holloway BT, Gerke DR, Call J, et al. “The doctors have more questions for us”: Geographic differences in healthcare access and health literacy among transgender and nonbinary communities. QSW: research and practice. 2023;22(6):1073–91.

Taylor T. “The State of Trans Healthcare Laws in 2025.” Advocates for Trans Equality. 2025.