As more individuals feel safe to accept and express their gender-nonconforming identities, gender-affirming surgeries are on the rise. The Aesthetic Plastic Surgery National Databank Statistics for 2020-2021, gathering data from 294 plastic surgery practices across the US, show that there were 4,489 gender-affirming surgery procedures, a 216% increase from 2020.

Gender-affirming surgeries take the form of top surgery (breast augmentation or a double mastectomy), bottom surgery (vaginoplasty or phalloplasty), and a variety of smaller feminization (tracheal shaving) and masculinization (chin augmentation) procedures. For those unable to afford a double mastectomy, binders, or undergarments which flatten the chest, are a temporary, but also restrictive, solution.

“I got my first binder and it was so hot and sweaty and incredibly uncomfortable. I felt like I was constricted and metaphorically choking. Emotionally I often associated my breasts with shame … I started talking to other people who were considering top surgery. It was the first time I thought, ‘Wow I could just get rid of them,’” recalls Kase Hohlt in The Aesthetic Society’s Beyond the Before and After docuseries. After undergoing a double mastectomy, Hohlt felt an immense sense of relief. “Being able to look at myself and to see that dude that I’ve always wanted to see is so cool. I’ve always been the same person, but I just became the realest, most authentic version of myself. In the end I consider myself incredibly lucky,” they state.

LGBTQ advocate Trev Flash’s journey to top surgery was a long and winding one. “I'm someone who grew up in a town where there wasn't much trans-ness. I came out as nonbinary first and it was only later in life that I made a link between the way I felt about my body and being trans,” they recall. “But I've always had an issue with my chest. I had tried different processes of learning to accept it, learning to love it, and quite clearly, it just wasn't right for me. In realizing that top surgery was a possibility, I didn't have to live with this negative feeling about myself.”

Flash then consulted their doctor about getting a consultation at the gender identity clinic, which handles surgery requests in the UK, four years ago. To this date, they still haven’t been contacted by the NHS services. “For non-private healthcare, nonbinary identities aren't taken as seriously as if you were a binary identity. If I was a trans man, then it would be more likely that they would approve it, because you also have to get signed off by a psychologist,” they explain.

Nonetheless, they saw the initial wait time as an opportunity to evaluate the necessity of the procedure, which even after a few years, was still undeniable. Flash was able to raise enough money through a fundraiser to pay for their consultation, and through a personal loan, was able to finance the surgery in May 2020.

Despite these hurdles and a challenging recovery process, which required a second revisional surgery, Flash has seen many great benefits to the procedure. “The actual freedom of living is fantastic. I definitely feel way more connected to my body. I was very much aware that the surgery wouldn't fix all of my body issues,” they note. “But what it has done is helped me see my body as a whole, and that’s been really great for my confidence building.” Flash echoes the sentiment that wearing a binder causes discomfort, as well as chest and back issues—a problem they no longer have to contend with as a result of the surgery. “Despite the hiccups and the fact that I did have to borrow money, which will take a really long time to pay back, it's totally worth it. The good outweighs the bad,” they proudly state.

Issues of Access

It bears emphasis that the emotional, psychological, and physical stakes at hand in gender-affirming surgery go far beyond external insecurity. Flash adds: “I know it might be seen as cosmetic, but it's not. It’s essential to me, for my well-being. You can't just go and get top surgery on a whim. Even if you had all the money in the world, you would still have to jump over these hurdles.”

55% of those seeking coverage for transition-related surgery are being denied by their medical insurers, and with economic uncertainty and rising cost of living only placing higher burdens on personal pockets, the number of patients able to cover the costs of surgery is going from few to even less. In 2021, nearly 30 million US citizens did not have health insurance, and transgender adults are more likely to be uninsured than their cisgender counterparts (19% versus 12%), creating unequal healthcare access. Given the long wait times and economic barriers, many have used platforms such as GoFundMe or Kickstarter to help them finance the surgery.

“Every day I see people crowdfunding for their surgeries. Through community care and support, we are able to help so many folks achieve these goals, but honestly, this should not be our burden to bear,” Leola Davis, founder of queer and Black-owned esthetics studio Pansy Esthetics, observes. Davis offers post-op treatments for top surgery patients, and skin/scar revision using enzyme therapy, and sees these surgical procedures as “life-saving and life-changing. I wholeheartedly believe that gender-affirming care should always be covered by insurance and that people shouldn't have to get clearance from therapists or psychiatrists to be approved for these surgeries. Cis people getting breast implants, face lifts, or BBLs are also gender-affirming surgeries, but they are not required to obtain the same clearances.”

Maya Benayoun, CEO at BeautyFix MedSpa, which offers surgical treatments like BBLs and breast augmentation, proclaims: “It's a very expensive surgery. Most people don't just have $10,000 to shell out on a surgery, and especially if they feel that their identity is not what they're currently sitting in, then they should be able to change it. Maybe if there's enough of a push, we'll see healthcare covering these things. As of right now, what we have is all these payment plans that are interest-free and can help a patient maybe access the funds quicker, but there obviously is no insurance covering it, so it is unfortunate.”

The wait to get a loan approval or bootstrap money isn’t just a financial burden, but an emotional one as well. “Living with gender dysphoria can be incredibly challenging and trying for patients. It can contribute to suicide, and all sorts of other very negative life, social, and wellness impacts. It's heartbreaking,” says Dr. Bella Avanessian, an Assistant Professor of Plastic and Reconstructive Surgery at Mount Sinai. “After surgery, patients often express such relief, and euphoria at times, of just finally feeling more comfortable in their skin, or being able to take a shower and clean their bodies without dread. Frequently, my patients express gratitude that I've saved their lives. It’s heartwarming to see plastic surgery have that kind of impact on someone.”

Dr. Avanessian performs the full spectrum of transgender surgeries, from vaginoplasty, for which she notes “there are very few training opportunities,” to breast augmentation, chest masculinization, and facial feminization procedures. For those seeking these procedures, the multidisciplinary team at Mount Sinai means that potential patients are screened through the outpatient center, assessed by a mental health team, social workers, psychiatrists, and a medical team, in accordance with World Professional Association for Transgender Health (WPATH) guidelines, “making sure that patients are optimized in terms of their health, social choices, and their social support, emotional support, and well-being,” Dr. Avanessian says.

Leveraging Expectations

The need for change extends far beyond the surgeries themselves. Practices need to not only offer patients a welcoming space, where their gender identities are acknowledged and respected, but also be realistic about the outcomes and restrictions of surgical procedures.

While social media has been a huge platform to bring awareness to the trans community, it can also set false expectations for surgical procedures. “The big problem I have seen in the last decade is the immediacy of plastic surgery. Social media has forced people to watch content that shows a ‘before and after’ in a very fast-paced format,” gender-nonconforming beauty expert Joseph Harwood notes. “I don’t think that it is a great representation of surgery and the information around post-surgery care, ongoing care, and maintenance isn’t shared at all, particularly around nonsurgical procedures like fillers, which are unregulated in a lot of ways.”

Leading with authenticity and integrity is key. As aesthetician and aesthetics educator Chandra Bredel remarks: “The biggest challenge is the rush of unlicensed influencers and celebrity lines flooding the marketplace with misinformation in a money grab [effort]. The individual transgendered person is not being supported by these offerings simply because too many of these influencers do not understand the complexities of being trans, nonconforming, or intersex.”

Future Perspectives

Regardless of what specific services a company offers, there are some universal alignments across the board. Educating service providers on pronouns and inclusive language is one.

Dr. Avanessian acknowledges that the road towards inclusivity can have its bumps, but that humility and integrity go a long way. “One important thing that I tell a lot of providers who haven't spent much time with transgender patients is that you are going to make mistakes. If you blurt out the wrong pronoun for example, the best thing to do in that scenario is to pause, apologize, and correct yourself, because it really makes a huge difference when you do that,” she states. “Another thing is if you hear someone misgendering a patient or, much rarer, being purposefully rude or offensive, it's a good idea to stand up and say something. Even if it doesn't change the behavior of that person, it really changes the experience, the isolation, and all of the negativity that that patient has been just silently dealing with in that moment.”

Speaking out on the subject of gender-affirming surgery means bravery on many levels. In the process of securing interviewees for this article, some individuals had to turn down the offer due to potential death threats being made to patients and surgeons alike, which shows just how far societal barriers still need to be broken down.

With Britain’s only gender identity clinic for trans children and young people being shut down, access to these life-saving surgeries is becoming even more difficult. This doesn’t only mean restricted access to surgeries, but other healthcare options like testosterone. Those now unable to receive these hormones through the UK’s NHS will need to pay £150 ($177) a month for their prescription, like Flash, who was cut off without notice. “It’s not feasible for people that are on low income or in debt. Think about the impact on their mental health of taking away that healthcare,” they comment. Those unable to secure their testosterone or estrogen privately will need to resort to the unregulated black market, putting their personal and legal safety at risk. Given the fact that in the US, transgender individuals are more likely to live below the poverty line than non-transgender individuals (26% versus 15.5%), these issues are equally prevalent across the pond.

The current social and political situations across the world present life-threatening dangers for trans people wanting to simply live life as their most authentic selves. A recent shooting at LGBTQ nightclub Club Q in Colorado Springs cost five innocent lives and left 25 injured, while UK Prime Minister Rishi Sunak’s plans to review the Equality Act 2010 could strip the trans population of their discrimination protection rights. If this is the state of affairs in even the most seemingly liberal of countries, how are those residing in countries where LGBTQ rights look even more bleak managing to cope?

“I do worry about how the future looks for trans people. But I also know that we'll find a way to fight. Because of government policies, we may be forced to go elsewhere and build these underground networks to support each other, but that's what we're here for,” Flash says. “As a queer trans person, you're used to being told to do things your own way. No matter what people do, we’ll always find a way.” Hopefully, with the support of allies, they won’t have to make the journey alone.