Barriers to Gender-Affirming Surgery Persist Despite High Satisfaction Rate

Access to gender-affirming surgery (GAS) was often blocked by barriers for transgender, nonbinary, and gender diverse (TGD) individuals looking to undergo the operation. A new analysis published in JAMA Network Open found that this care was often still inaccessible despite high reports of satisfaction in those who are able to receive it.¹

There are approximately 1.6 million individuals who identify as TGD in the US.² Some TGD individuals experience gender dysphoria and seek out GAS to align their physical bodies with their perceived gender to improve their mental well-being. In the past, TGD individuals have expressed difficulty in obtaining this care despite the potential benefit, with insurance coverage varying widely across the country. This study aimed to assess satisfaction with GAS and describe the barriers to obtaining GAS.¹

LEGACY, a longitudinal cohort of adults in Boston and New York City who identified as TGD, was used for data in the cross-sectional study. Participants were members of community health centers that specialized in gender minority health care. Individuals who self-reported as TGD, were 18 years or older, had signed a patient consent form, and had a medical visit within the previous year were eligible for the study. Participants also needed to complete an electronic survey at baseline between February 2019 and March 2021 to be included.

Demographics were self-reported, including gender identity, racial identity, education level, HIV status, health insurance, and lifetime use of hormone therapy for gender-affirming care. The Patient Health Questionnaire (PHQ-4) was used to assess psychological distress within the previous 2 weeks, and 1 question from the Short Form Health Survey was used to assess general health. Participants indicated if they were completing the form during the COVID-19 pandemic.

All participants were asked when they had first sought out GAS, their desires for surgery, surgical history, unmet needs, and barriers related to obtaining GAS. Participants indicated the anatomical region of their surgery—head, chest, abdomen, reproductive, or genital—and were allowed to pick more than one as needed.

There were 2176 participants with a mean (SD) age of 30.3 (10.3) years who were stratified by gender identity. Transgender men made up the most participants (40.3%), followed by transgender women (28.9%), nonbinary individuals assigned female at birth (24.7%), and nonbinary individualsassigned male at birth (6.2%). A total of 29.1% of the participants identified as a racial minority. Gender-affirming hormones were used by 81.2% of the participants.

At least 1 form of GAS was undergone by 43.5% of the participants, with region varying based on gender identity. A total of 82.0% of those who received GAS reported high satisfaction, with reproductive surgeries scoring a mean (SD) of 4.6 (1.0) in satisfaction out of 5 and the lowest mean score being a 3.8 (1.1) for head and neck procedures.

Double mastectomies were the most common procedure in transmasculine patients (45.1%), whereas orchiectomy was the most common in transfeminine patients (15.5%). Desired and unmet surgeries included uterus removal in 61.4% of transmasculine patients and facial feminization in 67.6% of transfeminine participants. Oophorectomy, cervix removal, labiaplasty, and vaginoplasty were all desired surgical procedures that were not met.

Almost all (94.4%) of the participants had come across at least 1 barrier to GAS. These included worries about medical complications, logistical constraints, cost, concerns about postoperative care, and lack of clinicians to complete this surgery.

Higher odds of surgical satisfaction in transmasculine patients were found in those who were younger than 40 years (18-24 years: adjusted OR [aOR], 3.49; 95% CI, 1.55-7.89; 25-29 years: aOR, 2.23; 95% CI, 1.13-4.41). Lower odds of surgical satisfaction were found in transmasculine patients without insurance and who were HIV positive. High surgical satisfaction was lower in transfeminine patients without insurance (aOR, 0.09; 95% CI, 0.02-0.49), whereas gender marker change (aOR, 2.65; 95% CI, 1.27-5.53) and a high self-rated general health (aOR, 2.21; 95% CI, 1.22-4.02) were associated with high satisfaction with GAS.

Barriers to GAS were most common in those who were aged 18 to 24 years, had any hormone use for gender-affirming care, or had clinically significant psychological distress.

There were some limitations to this study. The sample may not be generalizable outside of Boston and New York City. Access to surgeons is possibly higher in an urban setting compared with a rural setting. The northeast region of the US does not have the same sociopolitical environment as the other regions, which may make it ungeneralizable outside of the region. Measuring clinical surgical outcomes was not originally the intent of LEGACY being created, which encourages future studies to use a cohort to assess for this specifically.

"Our study of more than 2,100 transgender, nonbinary, and gender diverse adults found a strong desire for gender-affirming surgery, yet widespread unmet need: 94% reported barriers to care, and fewer than half had received surgery. Among those who had surgery, 82% reported high satisfaction, underscoring both the value of these procedures and the urgent need to reduce barriers to ensure trans people can access the life-saving care they need," David Pletta, PhD, MPH, lead data scientist at the University of Michigan and coauthor of the study, said in a statement to The American Journal of Managed Care®.

The researchers found that there was a high unmet need for certain types of GAS in TGD individuals, but barriers to care often prevent these surgeries from being accessible.

“The findings suggest that comprehensive efforts are needed within health care systems to improve access to GAS…as access to GAS can advance social affirmation, feelings of mind-body congruence, and psychological well-being for TGD patients,” the authors concluded.

References

1. Pletta DR, Quint M, Radix AE, et al. Gender-affirming surgical history, satisfaction, and unmet needs among transgender adults. JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494

2. Seven things about transgender people that you didn’t know. Human Rights Campaign. Updated April 24, 2024. Accessed September 18, 2025. https://www.hrc.org/resources/seven-things-about-transgender-people-that-you-didnt-know