Gender-affirming surgeries tripled in the U.S. between 2016-2019, study finds

The number of gender-affirming surgeries taking place in the U.S. nearly tripled between 2016 and 2019, according to new national estimates from a cohort study in JAMA Network Open.

Over 48,000 people got some type of gender-affirming surgery between 2016-2020, with a slight decrease in the number of surgeries performed in 2020, likely because of the pandemic. Breast and chest surgeries, genital surgeries, and other facial or cosmetic procedures increased during that time period across age groups.

Over 56% of all surgeries in the four-year period were breast and chest procedures. People ages 19-30 were the recipients of over half of all surgeries, while youths ages 12-18 made up a small portion at 7.7%.

Researchers analyzed data from 2016-2020 in the Nationwide Ambulatory Surgery Sample (which collects from hospital-owned facilities) and the National Inpatient Sample (which collects from community hospitals), identifying patients who had diagnosis codes that indicate transgender experience, along with occurrences of gender-affirming surgeries.

The analysis comes at a time when evidence-based gender-affirming care is under attack across the country. Twenty-two states have at least attempted to ban care such as hormones and surgeries for youth, and misinformation about kids and gender-affirming care is rampant.

But the study confirms that surgical interventions for trans youth are rare. During the four-year span, 3,678 people ages 12-18 received any type of gender-affirming surgery. The vast majority — over 3,200 — were breast or chest surgeries. In four years, only 405 youths across the country received genital surgery.

“I do not know of a single patient who’s ever had any kind of genital surgery under the age of 18, of the hundreds, potentially thousands of kids that I’ve cared for,” said Katy Miller, the medical director of adolescent medicine at Children’s Minnesota. “So the idea that it’s easy to get gender-affirming surgery, I mean, any queer or trans person will tell you that’s simply not true.”

It’s unclear exactly why the overall number of surgeries has increased so dramatically since 2016. Jason Wright, a physician at Columbia University and lead author of the study, noted that changes to insurance coverage of the care may be a factor. In 2014, the Obama administration lifted a ban on Medicare coverage of gender-confirmation surgeries, while more private insurance companies were also beginning to cover the procedures around that time.

Wright also pointed to the increase in medical evidence regarding the safety and benefits of these surgeries, as well as greater awareness of gender-affirming care options among patients.

Surgeons who specialize in gender-affirming procedures say that there has also been an increase in professionals who are trained and actively performing the procedures in the U.S. since around 2016. In the past, patients who wanted genital surgery in particular would often have to travel abroad to receive it. Still, “my sense is there still probably are not enough surgeons who understand this care and who are providing these services,” Wright said.

While experts in trans health issues suspected that surgeries had increased in recent years, no strong data had previously been able to quantify trends, Wright said.

“In the early era of Trump, at least anecdotally, there was kind of this sense of urgency of people being like, ‘Let me do this before I can’t,’” said Avery Everhart, an assistant professor at the University of British Columbia who focuses on transgender health and human rights.

She noted that it’s hard to contextualize the increase in surgeries because there is no reliable, nationally representative baseline estimate of how many transgender people there are in the U.S. Census data, for example, does not include any information about whether respondents are cisgender or trans.

The study also lacked more extensive demographic analysis, particularly on patients’ race, as the Nationwide Ambulatory Surgery Sample does not include race or ethnicity information.

Many public attacks on, and attempts to restrict, gender-affirming surgery focus on the possibility that people may regret having the procedures done. But a recent JAMA Surgery study focused on gender-affirming chest masculinization surgeries found that people rarely regret the surgeries. On a 5-point scale, the average level of satisfaction with the decision was 4.8. In a systematic review of studies that have looked at regret for other, unrelated procedures, including breast cancer treatment and reconstruction, all but one showed participants had higher rates of regret than those who received the gender-affirming chest masculinization surgery.

As attacks on trans health care continue, Wright said it will be important to continue to monitor trends in access to surgical care, including barriers such as wait times.

“We want to make sure that patients have access to care and there are adequate medical professionals who are available to care for transgender patients and that are able to provide these surgical services,” he said.