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Gender-affirming surgery disappeared from the U.S. for decades. Now the field is fighting to keep its gains

By Theresa Gaffney
From STAT

Gender-affirming surgery disappeared from the U.S. for decades. Now the field is fighting to keep its gains

For patients who receive gender-affirming surgery, the experience can feel like a rebirth.

"I decided that the old me would die on the table and then the new me would come up from it," said Wendy Grogan, 48, a trans woman who recently pursued vocal and facial procedures, top surgery, and a vaginoplasty -- the creation of a vagina from a penis, scrotum, and other tissue.

She knows that imagery may sound grim, but before she realized she was trans, she spent her life waiting to die. "It was a mercy killing."

Grogan is one of the thousands of patients in the U.S. who receive gender-affirming surgery each year. An increased demand -- which experts attribute to improved health coverage, rather than a surge of people coming out as trans -- means that the field has changed remarkably in the past 10 years. Medicare lifted a ban on coverage in 2014 and began paying on a case-by-case basis, with some state Medicaid programs and private insurance companies following suit. From 2016-2019, the number of all types of gender-affirming surgery performed in the U.S. nearly tripled from around 4,500 in a year to 13,000. Within that, the number of genital surgeries went from about 1,600 to 4,000. More physicians sought training, which then brought advances in surgical techniques and even greater access for patients.

That progress is now in jeopardy as trans people and their medical care have become a major flashpoint in U.S. politics, with 26 states passing legislation limiting access to gender-affirming care for youth since 2021. While most legislation focuses on minors, more lawmakers are attempting to restrict adult access as well. Last year, lawmakers in Texas tried to ban surgery for anyone under 26 years of age, while others in Florida and Oklahoma have proposed blanket bans on gender-affirming procedures for people of any age.

A handful of states have already banned state Medicaid coverage for gender-affirming surgeries. And President-elect Donald Trump has pledged to target trans health care in his administration, including removing federal funding from hospitals that provide gender-affirming care.

Trans patients and advocates are concerned that politicians could claw back access to surgeries that are life-changing for so many. To get a deeper understanding of the procedures beyond the rhetoric, STAT spoke with patients, researchers, and surgeons who have first-hand experience about what the process is like, how it's evolved in the U.S., and the challenges that lie ahead.

Harrison, a trans man living in the Southeast, knew immediately that when he got his new penis he wanted to be able to pee standing up. That meant that his phalloplasty -- a procedure where the surgeon builds a penis out of skin and a vein from the patient's arm -- had to include the extra step of lengthening of the urethra.

It was an easy decision for Harrison, one that was based at least partially on safety. He works as a firefighter paramedic, and often has to shower in communal bathrooms -- but before he got surgery, he might not have showered at work at all. He looked like any cisgender man when clothed and wasn't out as trans to his coworkers. It meant he could spend a three-week deployment fighting fire either not showering, or poking holes into water bottles to clean himself in rare moments of privacy. And if there wasn't anywhere to go to the bathroom in private -- whether at work or elsewhere out in the world -- he'd hold it.

"That's really what pushed me over the edge," he said. "This is a serious commitment. This is not just a couple incisions here and then bada bing, bada boom."

(STAT is identifying some patients in this story, like Harrison, anonymously or only by their first names due to safety and privacy concerns. Some are not publicly out as trans. Others are, but want to protect themselves from discrimination and harassment.)

Bottom surgeries are perhaps the most complicated and politically contentious of the gender-affirming procedures. Phalloplasty and vaginoplasty are the best-known procedures, but there are many more options. Even in surgery, gender is anything but binary.

After a vaginoplasty, patients need to dilate regularly by inserting a tube into the vagina, in order to maintain health and shape. They do this frequently in the days after the surgery, and then less as time goes on. But some version of it will need to happen for the rest of their lives. If that is unappealing, patients can opt for an alternate procedure called a vulvoplasty, in which surgeons create external genitalia sans vagina. There's also an orchiectomy, which is simply the removal of testes.

For masculinizing surgery, a metoidioplasty involves the creation of a penis made from a patient's hormonally enlarged clitoris. This procedure also comes with the option to lengthen the urethra or not. For some, peeing is not a concern worth the added risk of complications and revisions.

Grogan had no idea what kinds of physical changes she might want to make when she first realized she was trans, at age 45. "I had never knowingly interacted with a trans person at that point in my life," she said. "I was literally starting from scratch." Coming out to herself as trans was like finally solving a math equation that for years, "I would not allow myself to solve," she said. She spoke with her wife, their therapist, and her doctor. She knew she wanted vocal, facial, and top surgery. She was tempted by bottom surgery, but it took meeting the surgeon and feeling that she could trust him before she was ready to make the decision.

Surgeons typically require at least one consultation before scheduling bottom surgery. There can be a months or years-long waitlist for those meetings, then a similar delay before an operation date. Patients often need to provide referral letters from mental health providers and show that they've been taking hormones for at least a year. It's a long process filled with administrative hurdles. But with each successive surgery, Grogan felt closer to her true self.

"I wake up and I'm happier," she said. "I see things in the mirror that I want to see. And it's just absolutely amazing."

Survey data from the 2015 U.S. Transgender Survey, which includes nearly 20,000 people, showed that receiving gender-affirming surgery was associated with a 42% reduction in psychological distress and 44% reduction in suicidal ideation when compared to those who wanted it but hadn't gotten it.

It may seem paradoxical that a medical intervention can be seen as lifesaving, while also involving so much active choice. The potential regret somebody might feel after surgery is a point of major contention in the cultural arguments over young people's access to gender-affirming care. When it comes to surgical treatment (which minors receive extremely rarely), one meta-analysis from 2021 shows that less than 1% of participants who had any gender-affirming procedure regretted it. The exact percentage of people who "detransition" is likely low as well, but research is limited and the experience is more complicated than politics portrays.

Despite the increase in surgeries over the years, it's a "perpetuated misconception" that brand new swaths of people who want surgery are appearing out of nowhere, or have somehow been lured into making these decisions, said Devin O'Brien-Coon, a plastic surgeon and clinical director of the Brigham & Women's Center for Transgender Health in Boston. He and others note that it's actually impossible to say if demand itself for gender-affirming surgeries has truly increased, because the U.S. has never had the capacity to meet existing requests.

Now, surgeons all over the country see anxiety in patients over the future of these procedures, but their own opinions vary on just how much the political climate may affect surgical practices.

"It should be no surprise that trans people that are listening to [attacks on transgender rights] are like 'Jesus, insurance covers my surgery today, but are they going to cover it next month, or in the new year?'" said Maurice Garcia, the director of the Cedars-Sinai Transgender Surgery and Health Program in Los Angeles. Still, some clinicians doubt that the surgery could completely disappear the same way it did decades ago. Despite political pushback, there's more acceptance of trans people both in American culture at large and in medical settings now than there was then.

"You can't really put the genie back in the bottle of pretending they don't exist," said O'Brien-Coon.

While gender-affirming surgeries are on the rise in the U.S., the procedures themselves aren't new. Many historians date the first genital surgeries to the 1920s in Berlin. And it's said that Roman emperor Elagabalus begged doctors for female genitalia.

In the U.S., the first gender-affirming surgery clinic opened in 1966 at Johns Hopkins, hoping to provide trans people with the relief that psychoanalysis couldn't provide. The surgeries had already been performed for 15 years in Europe, and about 2,000 times total worldwide. But the Baltimore clinic closed just 13 years later, after being met with intense bias and stigma from hospital leaders. (The then-head of plastic surgery once described transgender patients as "hysterical," "freakish," and "artificial.")

For the rest of the century, trans patients who wanted to receive genital surgery often had to go abroad to Thailand, Serbia, or other places where industries blossomed with no American competition.

Stigma kept clinicians away. "Nobody really wanted to treat [trans patients] because they felt like treating them would be a commitment to take care of them long term, and they didn't want to be associated with that patient population," said Garcia.

While top surgery could be performed relatively easily -- it's similar to breast augmentations or reductions done on cisgender people -- only a few Americans continued to offer bottom surgeries.

One of those experts was Stanley Biber, a pioneer of vaginoplasties in the U.S. and perhaps the country's busiest gender-affirming surgeon. Biber began performing surgeries during the years that the clinic at Hopkins was still open. And for decades after it closed, he continued in the small town of Trinidad, Colo.

Patients came from all across the country for surgery. "It was a Greyhound bus and a cloud of dust," said Marci Bowers, past president of the World Professional Association for Transgender Health, who began her training in vaginoplasties with Biber in 2003, shortly before his retirement.

Bowers, a gynecological surgeon by training who identifies as a woman with transgender experience, is known as one of the first non-cisgender people to perform gender-affirming surgeries.

"In the case of an emerging field like this, where there weren't a lot of road maps on how to do things and there was so much room for improvement, you have somehow to have a lot of creativity," she recalled.

Trinidad was a small "Santa Fe Trail" type of town, Bowers said, where she and Biber were the only surgeons of any kind for miles.

The people stepping off the Greyhound bus were almost always alone, Bowers remembers. They were usually older, retired, single or divorced, and had lived much of their lives in the closet. After finally coming out as trans, they were often estranged from their families. Insurance wouldn't cover the procedure, so they always paid in cash. Afterward, they left town without knowing whether any other doctor might understand the procedure enough to be able to address potential future complications. They prepared for the long recovery alone.

After Biber retired, Bowers fully took over the practice. One evening, after meeting the first patient that she would operate on independently, she walked out of the hospital to see a huge double-rainbow spanning the horizon.

"I don't know if you believe in those kinds of things, but it was certainly impactful at the moment," she said.

Like Biber before her, Bowers operated alone for years, specializing in vaginoplasties. Clinicians remained hesitant about going into the field.

"I gave grand rounds in 2008, and was told 'be careful what you're known for," said Rachel Bluebond-Langner, a plastic surgeon at NYU who performs vaginoplasties. She and others had to confront a question without an answer: Would performing surgeries for trans patients make it harder, or impossible, to do other work?

But then things began to change, slowly. Attitudes shifted before access opened up.

"There still aren't enough providers, but [there are] a lot more than when I started. And a lot of them have had to make do with non-traditional training pathways," Garcia said.

Interested American surgeons often followed patients abroad to learn about the surgeries, then brought the skills back with them. Bluebond-Langner went to Thailand and Canada. O'Brien-Coon went to London and then to Spain. Garcia went to London for a year. Many surgeons could only observe rather than perform procedures while abroad, due to licensing restrictions. It wasn't an easy path, but the surgeons who pursued it saw a clear need for more clinicians.

"It wasn't until patients started coming to me with requests for gender care that I was really thinking about it seriously," said Fan Liang, the medical director of Johns Hopkins' Center for Transgender and Gender Expansive Health. After finishing a craniofacial fellowship in 2017, she initially focused her practice on facial reconstruction following shock trauma. But she soon learned that she could safely and effectively provide top surgeries and facial feminization. "When [patients] first came to me, I was like, 'I'm not the right person for you, find somebody who does this.' And then, when I did my own searching, I discovered that there were so few providers."

As more academic institutions in the U.S. open centers specifically focused on gender-affirming care, and more surgeons gained experience, more U.S.-based training programs have also cropped up. There are about a dozen different fellowships for trainees focused on gender-affirming surgeries. Still, experts say that more training programs and standardized qualification criteria are needed.

Gender-affirming surgeons are all board-certified in established specialties like plastics and urology. Then, each hospital uses its own criteria to assess surgeons' training specific to gender-affirming surgeries. But there's a big difference between a facial feminization surgery -- something any plastic surgeon should reasonably be able to do, O'Brien-Coon says -- and a complicated, collaborative phalloplasty.

"All of these surgeries live in the Venn diagram overlap of different medical specialties," said O'Brien-Coon. This means establishing these curricula could be complicated. Genital surgeries are often performed by multiple surgeons from different specialties, together. The many phases of a phalloplasty involve a gynecological surgeon, plastic surgeon, and urologist.

Collaboration can also make accountability trickier -- other surgical specialties have registries to share procedure outcomes, operated by professional surgical societies. This doesn't exist in any official capacity for gender-affirming surgery, perhaps because it's unclear what surgical specialty should take ownership, experts noted.

For patients, it can be difficult to know who the best surgeon is. As anti-trans attacks target hospitals, many institutions have removed basic information about gender-affirming care from their websites. Patients often go to online communities where people can post photos and talk about their experience.

"It's remarkable how cohesive and organized the community is, but that's not good enough. That's not the way it should be," said Alex Keuroghlian, director of the National LGBTQIA+ Health Education Center.

While the infrastructure around gender-affirming surgery needs to be built up more, experts emphasize that the surgeries themselves are much safer and more successful now than they were in the past.

"The success rates are quite high," O'Brien-Coon said about phalloplasties in particular, which are typically thought of as riskier than vaginoplasties. "In our current day, at the places that are known for doing this, the vast majority of patients who start and stick with it will get to the finish line with a successful result."

On a gray December day last year, Michael Parisi, a surgical physician's assistant who works with O'Brien-Coon, flipped through a pamphlet about phalloplasty with a 19-year-old patient who was in the office for his first consultation. The patient, a local college student, held a mechanical pencil and a spiral notebook filled with questions.

In a phalloplasty, the surgeon will remove a flap of skin from a patient's arm, re-attaches it to their groin, and carefully shapes it into a shaft. Later, in what's called a glansplasty, they'll make cuts around the top of the shaft to create the head. That's when "it goes from a skin-tube to a penis," O'Brien-Coon said.

"Is the glansplasty still done in stage one?" the patient interrupted Parisi at one point, looking at a graphic in the pamphlet. Parisi clarified that no, the pamphlet needed to be updated. The patient nodded -- he already knew from his research that stage two was best.

When O'Brien-Coon started performing gender-affirming surgeries about eight years ago, he and the rest of the field typically performed the glansplasty during the same stage of the phalloplasty as that transference of skin from the arm to the groin. But doing all this at the same time didn't work perfectly -- the organ was still a wound in its new home. This meant that surgeons couldn't be as aggressive in creating the ridge, and as it healed, the head flattened out. O'Brien-Coon used to perform innumerable revisions each year on this aspect of the procedure alone.

Now, O'Brien-Coon says that almost every phalloplasty surgeon -- or at least "every good phalloplasty surgeon" -- performs the glansplasty in the second stage of the procedure, months later, once more micro blood vessels have grown. He can't remember the last time he had to do one of these particular revisions.

It's a development that wasn't formally taught, but spread via osmosis as surgeons talked with each other.

"It's become more part of the mainstream in plastic surgery," O'Brien-Coon said. "That's accelerated the velocity at which the improvements occur and are probably disseminated."

And with more resources, Americans are making more advances. At NYU, Bluebond-Langner and another surgeon, Lee Zhao, have pioneered a robotic-assisted technique for vaginoplasties that shortens operating time which can in turn minimize complications. Those who do top surgery are trying to figure out how to maximize nipple sensation. For surgeons, the goal is to improve safety and patient satisfaction together.

People who receive gender-affirming surgery often want to think less about their body. When the procedures are done, after years of noisy dysphoria, they can finally find quiet. Surgeons say that's their motivation to learn and improve surgical techniques.

"The world is filled with diverse situations and people with diverse priorities," Garcia said. "We just simply need to recognize that and meet that standard."

At the end of the day in O'Brien-Coon's clinic, a 28-year-old who finished the last stage of his phalloplasty weeks beforehand came in for one of his last follow-up appointments. He traveled from his home in Delaware for the surgery, and for months had made the trek back regularly for follow-up care. When Parisi arrived in the exam room, the patient joked about his prepared list of questions for the clinician: "You already know!"

They discussed the technicalities of "milking," or making sure that all of the urine is out of the urethra after going to the bathroom. They reviewed how often the patient should be dangling his new penis outside of its post-operative supportive scaffolding -- he'd be "a full-time dangler" in a matter of weeks.

In a few months, the patient and his wife would be going on vacation to the Caribbean. And just like any other man, he hoped to go swimming without dysphoria, feeling at home in his body, or maybe without having to think about his body at all.

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