Examining the Prevalence, Satisfaction, and Barriers to Gender-Affirming Surgery Among Transgender Adults

Key Highlights

• The study results showed that 43.5% had any gender-affirming surgery (GAS) and 82.0% of those reported high satisfaction.
• 94.4% encountered at least one barrier to GAS, with cost being the most common (66.9%).
• Younger age was linked to lower odds of GAS and higher odds of barriers; gender marker changes and hormone use predicted higher odds of GAS.
• Desired but unmet procedures differed by identity: uterus/oophorectomy for transmasculine; facial feminization for transfeminine.

In a cross-sectional sample of transgender, nonbinary, and gender-diverse (TGD) adult primary care patients (N = 2176; mean age, 30.3 years), 43.5% reported having undergone at least one GAS procedure, and 82.0% of those reported high surgical satisfaction. Nearly all participants (94.4%) experienced barriers to GAS, most often cost. Desired but unobtained procedures were common and differed by gender identity.

Gender-affirming surgery is an established treatment for gender dysphoria and has been associated with psychological benefit. However, gaps in access persist, including insurance denials, limited availability of trained surgeons, and logistical challenges.

Investigators analyzed baseline electronic survey data (2019–2021) from LEGACY, a longitudinal cohort at two US community health centers specializing in sexual and gender minority care. Adults (≥ 18 years) self-identified as TGD and had a recent medical visit. Outcomes were receipt of any GAS, high surgical satisfaction (mean ≥ 4 on a 5-point scale), and barriers to GAS (eg, cost, waiting lists). Exposures included demographics, insurance, gender marker change, lifetime gender-affirming hormone therapy, psychological distress, self-rated health, and survey timing relative to COVID-19. Descriptive analyses and logistic regression models were stratified by transmasculine (TM) and transfeminine (TF) identities.

Overall, younger participants had fewer surgeries but faced more obstacles to obtaining care. Those with gender marker changes or prior hormone therapy were more likely to have undergone surgery. Conversely, lack of insurance was associated with lower satisfaction, potentially reflecting compromises in surgical quality or financial strain. (Table 1)

Table 1. Summary of key findings

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; GAS, gender-affirming surgery; TM, transmasculine; TF, transfeminine; Note: Arrows (↑, ↓) indicate direction of association relative to reference group.

This study has limitations. For example, the authors noted that the study is limited by its primary care patient sample, which came from two community health centers located in urban regions (Boston and New York City) that specialize in sexual and gender minority care. Such a sample may not be generalizable to other populations. The authors also noted the study design’s reliance on self-reported measures, including a single-item satisfaction rating.

“The findings suggest that comprehensive efforts are needed within health care systems to improve access to GAS (eg, improving referral pathways, training and hiring more surgeons competent in performing GAS), as access to GAS can advance social affirmation, feelings of mind-body congruence, and psychological well-being for TGD patients,” the authors concluded.

Reference
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