gender reassignment surgery psychological evaluation

Gender Affirmative Surgery Psychological Evaluations

If you or a loved one are in the process of transitioning or are looking to have a gender affirmative surgery,  we want to help .

Deep Eddy Psychotherapy offers psychological evaluations for gender affirmative surgery candidacy for our clients (ages 18 and up).  Our clinicians are dedicated to helping the transgender, non-binary, genderqueer, and gender-expansive community by providing this evaluation service along with individual, group, and couples therapy . 

We also recognize that transphobia and transmisogyny are interwoven into our society and that the mental health profession has had an unfortunate history of perpetuating these ideas.  Our therapists are committed to being part of the change for good and live more fully within our values – you deserve nothing less.

Ready to sign up to get an evaluation?  Don’t wait –  contact us  today.  Please read on to learn more about gender affirmative surgery evaluations and answers to common questions.

What is a gender affirmative surgery evaluation? 

Under the current guidelines, transgender, non-binary, and gender non-conforming clients seeking gender affirmative surgeries must have letters from mental health providers attesting to whether they meet the guidelines for surgical intervention established by the  World Professional Association for Transgender Health  (WPATH). 

Anyone who is seeking an attestation letter must meet with a mental health provider for an evaluation (typically just an interview, but occasionally more than one session) to determine whether they are good candidates for surgery.  Based on the results of the evaluation, the provider will write a letter summarizing your candidacy and their recommendations. 

Do you need an evaluation for hormone replacement treatment (HRT)?

No.  In Texas (and in most other states), we now use an informed consent model in place for HRT.  So, you no longer need letters from mental health providers in order to receive HRT.

What does a gender affirmative surgery evaluation assess for?

At Deep Eddy Psychotherapy, our clinicians recognize the inherent gatekeeping role that mental health providers have in this compulsory letter-writing process, and we seek to reduce any undue gatekeeping while also having to work within the structure of the WPATH Standards of Care.

Our clinicians who provide this service have a welcoming and affirmative stance toward gender-diverse clients and want to help clients receive the gender-affirming medical care they seek. We have training and experience in this area, and we actively consult with each other about the process.

We say all of this so that you can rest easier knowing that our process is designed with your rights in mind.  Our goal is not to keep you from getting the surgery you need, but rather to ensure that you are the right fit and have the support you need to succeed.

Some of the things your evaluator might ask about might include:

• Your gender story
• Past and current emotional wellbeing
• Social supports you can lean on
• What sorts of surgical interventions you are seeking
• Your understanding of the risks and benefits of surgery

Our providers understand that there is no one gender story narrative.   Your story is unique  and does not have to be tied together with a sense of certainty.  Likewise, our providers understand that your past and current emotional wellbeing could be impacted by both gender dysphoria and the effects of living in a cisnormative society, and we want to give you the support you deserve.

In addition to us asking you questions, we also welcome questions from the interviewee.  We recognize how hard it is to get to this point, and we want to be here for you however we can.

Who can write an attestation letter?

In Texas, some insurance companies require all letters to be written by doctoral level (PhD or PsyD) clinicians. Some insurance companies and surgery centers allow master’s level clinicians (LMFT, LCSW, LPC) to provide letters, but not all will.  To make matters a bit more complicated, some insurances and some procedures may require multiple letters from different providers.

Before scheduling a session, it can be helpful to talk with your insurance company and/or surgery center about what they each require in the letter and who can write the letters. 

If you do not have insurance, as advocates for equity and social justice, we do not want the ability to pay to keep you from receiving a letter from a mental health professional.  Please feel free to reach out to us if you have financial need, and we can let you know which clinicians have sliding scale spots open for this service at the time. 

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Preparing for Gender Affirmation Surgery: Ask the Experts

Preparing for your gender affirmation surgery can be daunting. To help provide some guidance for those considering gender affirmation procedures, our team from the   Johns Hopkins Center for Transgender and Gender Expansive Health (JHCTGEH) answered some questions about what to expect before and after your surgery.

What kind of care should I expect as a transgender individual?

What kind of care should I expect as a transgender individual? Before beginning the process, we recommend reading the World Professional Association for Transgender Health Standards Of Care (SOC). The standards were created by international agreement among health care clinicians and in collaboration with the transgender community. These SOC integrate the latest scientific research on transgender health, as well as the lived experience of the transgender community members. This collaboration is crucial so that doctors can best meet the unique health care needs of transgender and gender-diverse people. It is usually a favorable sign if the hospital you choose for your gender affirmation surgery follows or references these standards in their transgender care practices.

Can I still have children after gender affirmation surgery?

Many transgender individuals choose to undergo fertility preservation before their gender affirmation surgery if having biological children is part of their long-term goals. Discuss all your options, such as sperm banking and egg freezing, with your doctor so that you can create the best plan for future family building. JHCTGEH has fertility specialists on staff to meet with you and develop a plan that meets your goals.

Are there other ways I need to prepare?

It is very important to prepare mentally for your surgery. If you haven’t already done so, talk to people who have undergone gender affirmation surgeries or read first-hand accounts. These conversations and articles may be helpful; however, keep in mind that not everything you read will apply to your situation. If you have questions about whether something applies to your individual care, it is always best to talk to your doctor.

You will also want to think about your recovery plan post-surgery. Do you have friends or family who can help care for you in the days after your surgery? Having a support system is vital to your continued health both right after surgery and long term. Most centers have specific discharge instructions that you will receive after surgery. Ask if you can receive a copy of these instructions in advance so you can familiarize yourself with the information.

An initial intake interview via phone with a clinical specialist.

This is your first point of contact with the clinical team, where you will review your medical history, discuss which procedures you’d like to learn more about, clarify what is required by your insurance company for surgery, and develop a plan for next steps. It will make your phone call more productive if you have these documents ready to discuss with the clinician:

• Medications. Information about which prescriptions and over-the-counter medications you are currently taking.
• Insurance. Call your insurance company and find out if your surgery is a “covered benefit" and what their requirements are for you to have surgery.
• Medical Documents. Have at hand the name, address, and contact information for any clinician you see on a regular basis. This includes your primary care clinician, therapists or psychiatrists, and other health specialist you interact with such as a cardiologist or neurologist.

After the intake interview you will need to submit the following documents:

• Pharmacy records and medical records documenting your hormone therapy, if applicable
• Medical records from your primary physician.
• Surgical readiness referral letters from mental health providers documenting their assessment and evaluation

An appointment with your surgeon. 

After your intake, and once you have all of your required documentation submitted you will be scheduled for a surgical consultation. These are in-person visits where you will get to meet the surgeon.  typically include: The specialty nurse and social worker will meet with you first to conduct an assessment of your medical health status and readiness for major surgical procedures. Discussion of your long-term gender affirmation goals and assessment of which procedures may be most appropriate to help you in your journey. Specific details about the procedures you and your surgeon identify, including the risks, benefits and what to expect after surgery.

A preoperative anesthesia and medical evaluation. 

Two to four weeks before your surgery, you may be asked to complete these evaluations at the hospital, which ensure that you are healthy enough for surgery.

What can I expect after gender affirming surgery?

When you’ve finished the surgical aspects of your gender affirmation, we encourage you to follow up with your primary care physician to make sure that they have the latest information about your health. Your doctor can create a custom plan for long-term care that best fits your needs. Depending on your specific surgery and which organs you continue to have, you may need to follow up with a urologist or gynecologist for routine cancer screening. JHCTGEH has primary care clinicians as well as an OB/GYN and urologists on staff.

Among other changes, you may consider updating your name and identification. This list of  resources for transgender and gender diverse individuals can help you in this process.

The Center for Transgender and Gender Expansive Health Team at Johns Hopkins

Embracing diversity and inclusion, the Center for Transgender and Gender Expansive Health provides affirming, objective, person-centered care to improve health and enhance wellness; educates interdisciplinary health care professionals to provide culturally competent, evidence-based care; informs the public on transgender health issues; and advances medical knowledge by conducting biomedical research.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

Psychological Evaluation for Gender Affirming Surgery

Diagnosing gender dysphoria, gender affirming surgery is more than just a physical transition.

If your doctor is requesting you receive a psychological evaluation prior to gender affirming surgery, we can help. Before we do, we want you to know where we stand.

There are many ways people transition and different types of transitioning. We at Rock Creek Therapy do not agree with being arbiters of this transition process when physicians request it, and we advocate for change on those grounds. In the mean-time we will work with you to make this as easy a process as possible.

There are several steps we need to accomplish:

• Confirming a diagnosis in gender dysphoria.
• Assessing your ability and support system in the recovery process.
• Though we will not assess for it, we would also like to talk with you about your transition plan and what it means to you.

The assessment is primarily a clinical interview for 60-90 minutes and will cost $300 with a potential for reduced fees based on financial need.

Assessment Inquiry

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Contact us today about finding a therapist who is a fit for you.

Location of our Psychotherapy Practice

Rock Creek Therapy is located near Dupont Circle in Washington, DC.

We also conduct online therapy for residents of D.C., Maryland, Virginia, Michigan, Florida, Connecticut, Pennsylvania, and Illinois.

1350 Connecticut Avenue NW, Suite 1020 Washington, DC 20036 United States Directions

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If you have questions or if you’d like to discuss therapy options contact us at:

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For more about services and therapy session pricing please visit the Psychotherapy Services page

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• v.53(4); 2021 Oct
• PMC10165989

Gender reassignment surgery – a narrative overview of anaesthetic considerations and implications

Priyanka mishra.

1 Department of Anaesthesia, All India Institute of Medical Sciences, Rishikesh, India

Amborish Nath

2 Department of Burns and Plastic Surgery, AIIMS Rishikesh, India

Ashutosh Kaushal

3 Department of Anaesthesia, AIIMS Bhopal, India

Rakesh Kain

4 Department of Burns and Plastic Surgery, VMMC Safdarjung Hospital, India

The twenty-first century, with its transforming ideology and rising acceptance, is witnessing an increased number of transgender people applying for gender reassignment surgery (GRS). The procedure of GRS is a lengthy and complex one involving the active collaboration of multiple disciplines including psychology, psychiatry, family medicine, plastic surgery, endocrinology, otolaryngology, urology, gynaecology, maxillofacial surgery, and anaesthesiology. The considerable paucity of literature regarding the management of patients presenting for GRS places health care providers at a disadvantage. It is imperative to cautiously regard the specific medical, emotional, social, and economic concerns regarding these patients. Health care providers need to be trained well to deal empathetically with such patients. The present literature about GRS deals mainly with the surgeon’s perspective, while the anaesthetist’s approach remains hazy. This is because GRS imposes the need for anaesthesiologists to search for better and more efficient modes of anaesthesia so as to improve prognosis and minimize the associated morbidity. Anaesthetists should understand the associated psychological aspects and effects of hormone therapy while performing an extensive and informative pre-operative evaluation to formulate an effective strategy. Providing the optimal modes for anaesthesia and keeping a cautious watch for complications along with timely intervention in the advent of the same comprise the approach for high-quality anaesthetic care. This review aims to provide a detailed overview of significant considerations and competent peri-operative outcomes in patients presenting for GRS.

The right to gender identity is one that amounts to contouring an individual’s personality. The present hour calls for an understanding of the meaning that the term transgender holds. It needs to be recognized that sex and gender although often used interchangeably are quite distinct. Sex refers to the physical characteristics (e.g. reproductive organs, chromosomes, hormones) employed to assign people to be female, male, or intersex. However, gender is more of a social construct, sprouting from cultural expectations that shape an individual’s external appearance and conduct [ 1 ]. Gender identity disorders have been frowned upon throughout their existence, making their treatment quite controversial. Gender dysphoria, earlier known as gender identity disorder, describes a heterogeneous group of individuals having the desire to possess secondary sexual characteristics of the opposite sex and possessing varying degrees of dissatisfaction regarding their anatomical gender [ 2 ]. Gender reassignment surgery (GRS) has proven to be a revolutionary intervention for patients with gender dysphoria, hence playing a pivotal role in alleviating their psychological discomfort. GRS is a multidisciplinary endeavour requiring a collaborative effort of psychology, psychiatry, family medicine, plastic surgery, endocrinology, otolaryngology, urology, gynaecology, maxillofacial surgery, and, last but not least, anaesthesiology.

Though GRS is becoming popular and more acceptable, there is still a relative lack of awareness of the process and its associated challenges amongst healthcare professionals. GRS has been performed with various approaches, single and multiple settings, hence imposing the need for anaesthetists to search for better and more efficient modes of anaesthesia to improve prognosis and minimize the associated morbidity. Just as surgeons develop areas of specialization to better care for their patients, anaesthesiologists have specialized in out- and inpatient surgery, both cosmetic and reconstructive.

The vanishing stigma, increasing demographic and acceptance of transgender and gender non-binary (TGNB) individuals calls for the field of medicine to catch up too. Hence, it is only discerning to expect that in coming times, they will present more frequently in general surgical settings and as they do, we would be well prepared to provide them high-quality peri-operative care. The ardent need to review this topic is rooted in the acknowledgement that although there are articles discussing the surgical and peri-operative outlooks of this procedure, there is scarce literature about the role, considerations, and strategies for anaesthesia in these procedures. This substantial shortfall in the published literature regarding the holistic concerns of GRS demands further strategies to be explored. We have discussed the anaesthetist strategy governed by consideration of the psychological aspects, effects of hormone therapy, optimal modes for anaesthesia and cautious watch for complications along with timely intervention for handling the same for providing high-quality anaesthetic care. In this article, we aim to analyse, understand, and formulate an approach for the entire procedure from an anaesthesiologist’s perspective.

RESEARCH METHODS

For this review, we retrieved data by a systematic literature search carried out in the research databases including PubMed, EMBASE, and Google Scholar. We included review articles, original studies, and case reports in our search.

History and current scenario

Dr Alan L. Hart, a TB specialist in the US, became one of the first female-to-male transgender persons who underwent gonadectomy and hysterectomy for his gender dysphoria in 1917 [ 3 ]. According to the 2018 census, nearly 0.6% of adults in the United States, or 1.5 million individuals, make up the transgender community. The estimated transgender population worldwide in the 2018 census ranged between 1% and 2% of the total population, which is nearly 900 million people. The American Society for Plastic Surgeons (ASPS) has reported an expeditious rise in GRS of up to 155% within the span of 2016 to 2017 [ 4 ]. With the legalization of transgender in most of the countries throughout the globe, the curve of GRS surgery is probably going to run further upslope.

OVERVIEW OF THE PROCEDURE

As already described, GRS requires a multidisciplinary approach. To begin with, the guidelines for the Recommendation of GRS indicate that the patient should be physically and psychologically prepared for surgery and should have a clear perception of the interventions to be performed along with the risks and possible complications [ 5 ]. Preparation for GRS is a multistage process that includes an elaborate psychological and wellbeing assessment of the patient. This may take nearly 12 months for complete psychosocial preparation of the patient to deal with the transition. Psychological evaluation is then followed by feminizing or masculinizing hormone replacement therapy (HRT) prescribed by a consulting endocrinologist. There should be documented “real-life experience in the desired role” for at least a whole year [ 5 ]. GRS ensues at the end of this process. The algorithm for the entire procedure is summarized in Figure 1 .

Algorithm for the procedure of gender reassignment surgery

INITIAL EVALUATION

What is required is having an elaborate understanding and assessment of the patient’s psychological, medical, legal, and social concerns. In developing countries, a substantial proportion of this relates to social and psychological aspects. The mental wellbeing assessment aims at evaluating and treating the mental health issues, offering suggestions with peer support with or without family therapy, assessing the gender expression level and the readiness of the patient for fully or partially reversible and irreversible interventions [ 6 ]. A reassuring and sensitive attitude towards the patient affirming that they would receive the best available care without any judgment aids in alleviating their anxiety and concerns. A holistic approach to assessment involves the multidisciplinary effort of various medical teams.

ANAESTHETIC PLAN OF CARE

Pre-operative assessment.

Apart from the routine preoperative assessment as for any other surgery, here we need to address specific history, examination, and investigations. The aim should be at the optimization of the patient care through risk reduction and informed consent [ 7 ]. It also caters to efficiently preparing the patient for surgery and anaesthesia while encouraging their compliance and participation.

• The biological sex and current gender identity of the patient should be noted.
• In the absence of specific gender assignment, measurements and calculations with gender specificity become tricky, e.g. ideal body weight, target-controlled propofol infusion using Schneider mode [ 8 ].
• Medical concerns.
• Patient’s preferred form of address (i.e., title, name, pronouns).
• History of use of anti-depressants, anti-anxiety, and other psychotropic drugs should be derived.
• Higher risk of tobacco, substance abuse, and sexually transmitted diseases (STDs) should be taken into consideration [ 9 ]. The prevalence of HIV was found to be 8.2% in the Indian transgender community as compared to 0.31% national HIV prevalence in India [ 10 ].
• History of multiple silicone injections can cue towards the existence of granulomatous disease, pneumonitis, organ failure, and infection [ 11 , 12 ].
• Masculinizing or feminizing therapy with a detailed description of drugs.
• Duration of therapy.
• Should be done with due respect to the privacy and dignity of the patient while maintaining professionalism.
• A chaperone of the gender of the patient’s choice should be present during physical examination.
• Should include assessment of any restrictive lung disease (common in female-to-male [FTM] chronic chest binders) [ 8 ].
• Most of the parameters should be evaluated as per the patient’s biological sex.
• However, for patients who have received HRT for more than six months, it has been suggested to compare the laboratory values to their cis-counterparts rather than their biological sex [ 13 ].
• There is still limited evidence regarding interpretations in different stages of gender transition.

Investigations to evaluate effects of HRT:

• complete lipid profile to screen for dyslipidaemias;
• liver function assessment to screen for any liver dysfunction;
• complete coagulation profile;
• screening for thromboembolism, breast and endometrial malignancy [ 15 , 16 ].
• Recognition and management of depression, anxiety, and regret.
• Advice on quitting smoking and explanation of its implications.
• Discontinuation of HRT for nearly 2-4 weeks before surgery in consultation with the endocrinologist and surgeon, keeping in consideration that prolonged withdrawal of hormones may culminate in the reversal of desirable effects [ 17 ].
• Considering the use of low-dose aspirin along HRT to reduce the risk of thromboembolism.
• Patients should be well informed regarding the overall cost, duration of hospitalization, surgical and anaesthetic options, complications, and post-operative care, and consent should be obtained.

Anaesthetic implications and concerns of HRT

It is not only relevant but imperative for an anaes-thesiologist to be aware of the various effects of HRT as it can guide the formulation of an efficient plan for anaesthesia. The various medications given in feminizing hormonal therapy include gonadotropin-releasing hormone agonists such as leuprolide and goserelin, spironolactone (androgen blockers), oral, parenteral or transdermal oestrogens and 5-α-reductase inhibitors such as finasteride. These medications can pose a higher risk of endocrine (e.g., diabetes) and cardiovascular (e.g., hypertension, venous thromboembolism [VTE]) implications. Testosterone therapy has been associated with derangements in liver function, which in turn complicate the drug metabolism. These risks are higher in the patients receiving oral formulations, hence necessitating the discontinuation of HRT for a few weeks prior to the surgery [ 16 ]. However, the withdrawal of hormone therapy can potentially make these patients more emotional, with rapid mood swings. This in turn can pose certain challenges for the anaesthetist in patient handling in the perioperative window ( Table 1 ). Incidence of postoperative delirium and post-operative nausea and vomiting (PONV) has also been found to be higher in patients on HRT. Some cases have revealed the occurrence of migraines in patients on anti-androgens. It is important to remember that in many cases these patients require lifelong administration of HRT unless curtailed by severe adverse effects.

Anaesthetic implications and concerns of hormone replacement therapy

Intra-operative considerations

The intra-operative care of these patients is distinctive as it needs the discernment of special anatomical, psychological, physiological, and pharmacological issues as numerated in Figure 2 . An anaesthesiologist needs to pay close attention to the following considerations:

Intra-operative considerations of gender reassignment surgery

• There should be clear instructions to the peri-operative team to maintain minimum traffic within the operating room (OR), particularly when the surgery involves exposure of the chest and/or genital regions.
• The patient’s preferred pronouns should be known and used at all times by the peri-operative staff when addressing the patient and any unnecessary questions should be discouraged.

Modes of anaesthesia

CSE – combined spinal-epidural, GA – general anaesthesia, LA – local anaesthesia, PNB – peripheral nerve block, PONV – post-operative nausea and vomiting, PACU – post-anaesthesia care unit, HRT – hormone replacement therapy.

• Transfer and positioning of the transgender patients who have undergone external body contouring procedures can be challenging and needs to be done with utmost caution.
• FTM transgenders may be using chest wraps and breast binders that need to be removed beforehand. Though there is still insufficient literature on the topic, chronic use of these tight chest binders can pose the risk of a restrictive respiratory pattern [ 14 ].
• Interestingly, even the most routine procedure of urinary catheterization can get tricky and challenging in the patients who have already had GRS concerning the urethra done, e.g. metoidioplasty with urethral lengthening, phalloplasty, or vaginoplasty.
• Patients who have recently had various facial aesthetic procedures such as rhinoplasty or jaw reconstruction may pose a challenge during bag and mask ventilation and should be handled with care and caution.
• Patients who have had previous voice pitch altering surgery such as chondroplasty or laryngoplasty may present as a difficult airway scenario as they pose the risk of tracheal stenosis or perforation, vocal cord damage, and dysphagia. Hence, a difficult airway cart should be kept ready [ 22 ].
• It needs to be taken into consideration that transgender women suffer from higher rates of HIV infection and might be on anti-retroviral therapy (ART). The various sedatives, anxiolytics, hypnotics, and antibiotics may present significant interactions with antiretroviral agents and result in altered drug metabolism [ 23 ].
• As these patients have been off steroid therapy for few weeks, they might experience steroid withdrawal syndrome. This can be prevented by administering a steroid bolus of 100-200 mg hydrocortisone intra-operatively.
• An anaesthetist needs to be vigilant for elevated intraoperative risks due to the possible existing respiratory, renal, cardiovascular, and hepatic compromise of the patient.
• VTE is a major perioperative concern due to the use of HRT medications and needs to be looked out for and relevant preventive interventions should be adopted. Cautious haemodynamic monitoring needs to be done for the early identification and management of this dreaded complication. Intraoperative prophylaxis should be provided with subcutaneous heparin and graded compression devices.
• Higher incidence of stroke has been linked to greater erythropoietin production and haematocrit and hence increased blood viscosity, attributed to parenteral testosterone therapy. Therefore, adequate hydration should be maintained for the patient [ 24 ].
• Considering the extensive nature of surgery, efficient pain control is imperative.

COMPLICATIONS

GRS presents with its arena of complications to be looked out for and dealt with. Amongst them, certain complications demand the anaesthesiologist’s ardent attention ( Table 3 ). These patients may be suffering from anaemia owing to the multiple and prolonged operations they undergo over some time. This needs to be taken care of by adopting appropriate pre-operative optimizing and perioperative blood loss reducing strategies. Two of the dreaded complications that the patients on oestrogen therapy should be monitored for are pulmonary embolism (PE) and deep vein thrombosis (DVT) [ 25 ]. These haematological events are attributed to peri-operative immobility, but due to the thrombotic effects of transgender HRT, there is a considerably higher risk of the same in these patients. The range of occurrence of VTE in transgender women on oestrogen therapy is from 0% to 6% [ 26 ]. The hypercoagulable state resulting due to HRT medications (both male-to-female and FTM) can precipitate cerebrovascular accidents and myocardial infarction and also aggravate any pre-existing coronary disease. This in turn warrants maintenance of adequate hydration at all times along with utmost care during all the phases of anaesthesia, supplemented by cautious intra-operative monitoring.

Complications in gender reassignment surgery, associated risk factors and preventive measures

The extensive wound surface, adverse effects of steroid therapy, and repeated surgery make these patients more susceptible to various infections, necrotizing fasciitis, and septicaemia [ 27 ]. The various other surgical complications include gastrointestinal events (e.g., rectal injury and rectovaginal fistula) and urinary tract complications (e.g., urethral stricture, fistula, and incontinence). Some unspecific events such as inguinal hernia, compartment syndrome, and asymmetry can also be witnessed after the surgery.

POSTOPERATIVE CONSIDERATIONS

The challenges continue after the completion of surgery, as the post-operative period in these patients has its concerns of postoperative pain, anxiety, depression, withdrawal, and at times regret [ 28 ]. Amongst the other parts of a detailed handover to the post-operative care team, one of the most important is validation of the patient’s preferred pronoun and name to avoid any unnecessary and repeated questioning [ 8 ]. It should be ensured that there is a multi-pronged approach with optimal analgesic strategies to manage post-operative pain. This can include epidural anaesthesia, intravenous analgesics, peripheral nerve blocks, parenteral therapy, and patient-controlled analgesia (PCA). There should be a collaborative approach to tend to the patient’s mental health, as well as social and spiritual needs. Canner et al . [ 29 ] reported that transgender patients require a higher level of care, highlighting the significance of formal training of health care providers for best practices to encourage and achieve a respectful and holistic approach towards anaesthesia delivery. Early implementation of social work and community support in the postoperative period plays a major part to smoothen the process of discharge while assisting the transition to patient recovery.

IMPORTANCE OF TEAMWORK AND COLLABORATION

As already mentioned, the complex procedure of gender reassignment involves a multidisciplinary effort of psychology, psychiatry, family medicine, plastic surgery, endocrinology, otolaryngology, urology, gynaecology, maxillofacial surgery, and anaesthesia. Evaluation by mental health professionals for eligibility criteria is a precondition for GRS as it can be a physically, emotionally, financially, and socially overwhelming procedure. The plastic surgeons, otolaryngologists, urologists and all other contributing surgeons need to have clear and competent participation in this long-term therapy. The surgeon and endocrinologist should also collaborate in optimizing HRT withdrawal and restart in the peri-operative period. The current state of affairs is still lacking such a closed loop inter-disciplinary approach. Hence, an efficient and especially dedicated team can help in achieving the ultimate goal of quality management to harness favourable outcomes for the patient.

CONCLUSIONS

Various parts of the world still suffer through an under-representation of the transgender community which stays confined to the margins of society. However, there is no denying the fact that with the changing tide and rising acceptability of transgender persons, the field of medicine is going to be presented with an increased proportion of these patients. The specific emotional, physiological, and pharmacological concerns coupled with the collaborative interplay of multiple disciplines make this class of patients a challenging lot. It is the attitude, preparedness and prudence of the medical team that can bring about a favourable outcome. Proper training of various health care professionals appears imperative here to empathetically handle and efficiently treat these patients. We would not be wrong in believing that the quality care provided before, during and after surgery has a substantial impact on patient outcomes after GRS. This simultaneously deserves acknowledgement of the fact that extensive studies and evidence are needed to understand and define better strategies for perioperative care in patients presenting for GRS.

ACKNOWLEDGEMENTS

Financial support and sponsorship, conflict of interest.

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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

Nature Reviews Urology volume  8 ,  pages 274–282 ( 2011 ) Cite this article

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This article has been updated

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

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Principles and outcomes of gender-affirming vaginoplasty

Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review

The effect of early puberty suppression on treatment options and outcomes in transgender patients

Change history, 26 april 2011.

In the version of this article initially published online, the statement regarding the frequency of male-to-female transsexuals was incorrect. The error has been corrected for the print, HTML and PDF versions of the article.

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Is Counseling Needed Before Gender Transition?

• Psychological: Male
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For people with  gender dysphoria,  transitioning from one’s birth gender to their desired gender can be a big step. It can involve hormonal treatment as well as surgery. Some professionals recommend a mental health screening and psychotherapy beforehand as part of the process. But is that really necessary?

The AMA Journal of Ethics discussed the debate in a recent commentary.

On one hand, counseling can help patients better understand the complex procedures and the adjustments that will be needed, even if one has been living as their desired gender for a while. Also, many view gender reassignment surgery as permanent, and patients need to be prepared.

On the other hand, many patients are confident about their decision and see no reason for a mental health professional to intervene or approve the transition. Others feel that the transition can be modified if they change their mind, even if a complete reversal is not possible.

According to the commentary, the World Professional Association for Transgender Health (WPATH) advises mental health screenings and recommends psychotherapy before any body modifications are made. However, such decisions could be made on a case-by-case basis.

It is still important for patients to provide informed consent before any hormonal or surgical procedure is conducted, acknowledging that they understand the procedures, the risks and benefits, consequences, and alternatives, the commentary noted.

AMA Journal of Ethics

Murphy, Timothy F., PhD

“Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?”

(November 2016)

http://journalofethics.ama-assn.org/2016/11/ecas2-1611.html

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The psychological challenges of gender reassignment surgery

July/August 2007, Vol 38, No. 7

Print version: page 53

Surgery and hormonal therapy are increasingly common treatments for gender dysphoria, but the prejudice and discrimination transgender individuals face post-transition can cause significant psychological distress, says Marci Bowers, MD, a surgeon who performs gender reassignment surgery in Trinidad, Colo., and is herself transgender.

Post-change, many men and women deal with rancorous divorces, custody battles, job loss and rejection by family members, she has found. Some even commit suicide, continues Bowers, who will speak about the psychological impact of transgendersurgery at APA's 2007 Annual Convention.

"It's a wonder that anyone transitions-the penalties are so severe," she says.

Bowers wants to help dispel the myths and misperceptions surrounding transgender surgery-among them that transitioning individuals are really gay men or lesbians in denial or that they are mentally ill.

"Because dysphoria is currently listed as a psychological disorder, transgender [people] are assumed to be mentally ill," she explains. "This doesn't allow them to be treated equally, no matter how visually compelling the change is."

This stigma can have far-reaching psychological effects, Bowers says. "The transition provides great barriers to intimacy, and for a person's psychological well-being, intimacy is very important."

Psychologists can help transgender people overcome such barriers as therapists and also by researching and raising awareness about the social and economic barriers transgender people face.

--L. Meyers

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• Published: 26 August 2024

Health care needs and barriers to care among the transgender population: a study from western Rajasthan

• Tanvi Kaur Ahuja 1 ,
• Akhil Dhanesh Goel 1 , 2 ,
• Manoj Kumar Gupta 1 , 2 ,
• Nitin Joshi 1 ,
• Annu Choudhary 1 ,
• Swati Suman 1 ,
• Kajal Taluja 1 ,
• Madhukar Mittal 3 ,
• Navdeep Kaur Ghuman 4 ,
• Navratan Suthar 5 &
• Pankaj Bhardwaj 1 , 2  

BMC Health Services Research volume  24 , Article number:  989 ( 2024 ) Cite this article

Metrics details

Transgender people comprise an estimated 0.3–0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. Methodology: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. Results: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual’s health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. Conclusion: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

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Introduction

Universal Health Coverage (UHC) means that all people have access to quality healthcare services (service coverage) without any financial hardships (catastrophic health expenditure) [ 1 ]. To achieve UHC, National Health Policy 2017 projects to increase the government’s health expenditure to 2.5% of GDP by 2025 [ 2 ]. In alignment with this objective, the budgeted health sector spending has increased from 1.3% (2019-20) to 2.1% of GDP (2021–2022). According to National Health Accounts 2018-19, Out of Pocket Expenditure per capita (in Rupees) is 2155 [ 3 ].

Incidence of catastrophic health spending is felt at a higher rate by vulnerable communities due to gender, socio-economic position, disability status, or sexual orientation, besides other characteristics. The Transgender (TG) community is one such community whose gender expression (masculine, feminine, other) differs from their assigned sex (male, female) at birth. They can be identified as trans-man or trans-woman [ 4 ]. In the Indian context, transgender individuals identify themselves differently including Hijras, Aravanis, Kothis, Jogtas/Jogappas, and Shiv-Shakthis. For the first time, this population was included in India’s 2011 census. Reports suggest that 4.8 million Indians identified themselves in the ‘other’ category.

Recent legal and policy changes in India have significantly affected gender-diverse communities. The Transgender Persons (Protection of Rights) Bill formulated in 2014 went through changes over a period of 5 years and was finally declared an Act in 2019. The Act highlighted the need to prohibit discrimination including denial of service or unfair treatment in relation to healthcare [ 5 ]. With respect to UHC, there are evident disparities in service coverage across the transgender population [ 6 ]. Transgender persons face a disproportionate burden of certain diseases, including HIV, viral hepatitis, and other sexually transmitted infections. They also pose a higher risk for mental health issues or substance abuse. Literature also suggests that transgenders may seek gender-affirming health services apart from general healthcare services. This might involve counseling support for themselves and their family related to gender id entity or undergoing gender transitioning procedures and surgeries. Transition-related treatment may include cross-sex hormonal therapy, hair removal, and gender-affirming surgeries.

In India, there are significant disparities in the availability and accessibility of healthcare. Existing research has identified various challenges and barriers encountered by transgenders in accessing and navigating the healthcare system. These include a lack of provider expertise in transgender care, the gap in health systems delivery mechanisms, lack of culturally sensitive healthcare training, inadequate financial coverage or low socio-economic condition, and poor community health-seeking behavior [ 7 ]. Rajasthan is one of the high focus states under the National Health Mission [ 8 ]. Since Western Rajasthan is a desert area, healthcare becomes even more challenging [ 9 ]. It further causes adverse impact on the desire and ability of transgender people to access healthcare. Poor healthcare access and health outcomes among the transgender population can also be attributed to lower levels of health literacy [ 10 ]. Rajasthan is one of the states with the lowest literacy rates among the transgender population [ 11 ].

In order to improve the health of transgenders and address the barriers to healthcare, it is crucial to identify the health priorities. A growing body of research regarding the healthcare experiences of transgenders exists worldwide, but there is still a paucity of research in the Indian context. This study has been conducted with the aim of reviewing the health issues and challenges faced by them in the existing healthcare system in Western Rajasthan. Although behavioral and social factors play a pivotal role in transgender health, this research focused on health needs and healthcare system-related barriers and challenges.

Research questions:

What are the basic health needs of the transgender community?

What are the barriers they encounter in the process of obtaining healthcare services?

How are the experiences of transgender persons in healthcare facilities?

What is the level of knowledge among healthcare providers regarding health of transgender persons?

How can healthcare services be enhanced for the transgender population?

Methodology

The study was conducted in the state of Rajasthan during the year 2022.

Research Design: This study utilizes a descriptive qualitative research design to allow in-depth insight into the existing health-related needs of transgender persons, their experiences in healthcare facilities and the barriers they encounter in meeting their needs. The study was approved by the Institutional Review Board of All India Institute of Medical Sciences, Jodhpur in July 2022.

Setting: The study was conducted in a community-based organization.

Sampling and sample size: Purposive sampling was utilized for this research. Transgender people above or equal to 18 years of age residing in different geographical region of western Rajasthan were approached with the help of established Civil Service Organizations (CSO). People who responded back were included in the study.

Data collection: All recruitment and data collection procedures were completed by public health scholars trained in research under the supervision of a community medicine professor. Multi-stakeholder interviews were conducted. It includes identification of relevant stakeholders to understand facilitators and barriers of the topic of interest. The identified stakeholders included specialist healthcare providers, representatives of civil service organizations and transgender persons (target population). All the individuals who agreed to participate in the study were approached by the interviewer. They were explained the purpose of the study and an appropriate time was decided to ensure active participation. This was also done keeping in view the sensitivity of the subject matter. All the interviews and the focus group discussion were conducted face-to-face in English and translated to Hindi for participants who did not understand English. Key informant interviews ( n  = 7) of specialist healthcare providers central to providing transgender care were conducted. The specialists included of a psychiatrist, plastic surgeon, endocrinologist, gynecologist, and community medicine experts. All interviews with specialist healthcare providers had a duration of 20–30 min. Transgenders residing in different geographical region of western Rajasthan were invited for a focus group discussion (FGD). Informed consent was taken from all the study participants who agreed to participate in the study. Audio and video recordings were done for focus group discussion as well as key informant interviews. The focus group discussion lasted for 2 h. Apart from this, CSO representatives were also interviewed ( n  = 3) i.e., a nurse, social worker and the administrative head of the organization. Data was collected over a period of 2 months.

Before the focus group, socio-demographic data was recorded, including age, gender, education, and income. An FGD guide and interview schedules were prepared and used for focus group and key informant interviews, respectively. They were designed to cover information about:

Knowledge and experience on transgender issues.

Challenges in providing transgender care.

Methods for improvement of the healthcare system.

Analytic approach: Audio-recorded focus group data and key informant interviews were transcribed and translated into English by four researchers. The data obtained through key informant interviews were also transcribed. The data was analyzed manually using thematic analysis. The available data was actively and repeatedly read to familiarize and valuably orient towards the available raw data. Subsequently, codes were identified using an inductive approach i.e., they were reflective of the issues that were apparent in the data and were not dependent or guided by any existing theoretical frameworks. In the next step, themes were constructed by analyzing, combining, and comparing codes. The developed themes were such that they reflected the significance of the entire dataset. Lastly, the themes were reviewed, defined, and named, along with the identification of narratives that justify and explain all the mentioned themes. In the final stage of analysis, the identified themes from the coded data were used to construct a framework using grounded theory approach such that it accurately represents a concise picture of the data.

Ethical considerations: Confidentiality emerged as an ethical concern in this study. All transgender individuals were provided with detailed information about the purpose, procedures, potential risks, and benefits of research. Participants were ensured that their participation was voluntary, and they had the right to withdraw at any time without consequence. All data and identifying information collected during the discussion was restricted to the research team and anonymized to prevent identification of individual participants.

A total of 12 transgenders participated in the FGD. Their socio-demographic characteristics are summarized in Table  1 . All Participants in the study belonged to Rajasthan, India. Eleven out of the total 12 participants self-identified themselves as transgender woman. The mean age of transgender individuals who participated in the study was 23.8 ± 3.6. The selected cohort represented a range of educational qualifications from secondary school to post-graduation. The majority of the participants were employed, but none was employed in the government sector. More than half of the participating individuals had an income of less than INR 10,000 (66.7%) (Table  1 ).

Health needs of the transgender community

The need for regular screening of non-communicable diseases at peripheral healthcare centers was expressed by the transgender participants. Lack of accessible and/or affordable health services and social barriers contribute to anxiety and depression among them, which further leads to their inability to control the use of tobacco and alcohol. This indicates the need for mental health support tailored specifically for this population.

Healthcare provider 1 (HCP-1) “ Gender dysphoria is diagnosed in later stages of life, late adolescence, or early adulthood because individuals are not able to seek help due to a lack of knowledge on available medical options and familial pressure.”

Specifically, they expressed the need for public healthcare facilities to provide gender transitioning procedures ranging from hormone replacement therapies to sex reassignment surgeries.

Figure  1 illustrates coding tree for health needs of transgender participants.

Coding tree for health needs of transgender participants

Barriers enumerated by transgenders in accessing healthcare services were segregated into personal, healthcare system and social barriers (Table  2 ).

Personal barriers

Transgender participants revealed a lack of awareness regarding the provision of transgender identity cards being issued by the Ministry of Social Justice and Empowerment. Moreover, the growing need was identified to educate them regarding their entitlements which may have implications on health. These include but are not limited to recognition of their gender identity, provision of medical facilities for their surgical and hormonal needs, and facilitation of access in hospitals and other healthcare facilities. (Transgender Act 2019)

During a key informant interview, one of the medical practitioners highlighted the need to introduce and explain the range of medical options available to transgenders for their transition.

HCP-2 “ Internationally, I have worked in fertility clinics. Before undergoing hormonal therapies or surgeries, transgender patients usually preserve oocytes and sperms to bear children in the future. The basket of available options must be known to the community. This also improves their quality of life.”

The health outcomes of an individual are dependent on their timely health-seeking behaviors. An interview revealed that many transgenders prefer the traditional removal method of male genitals rather than conventional gender affirming surgery. This reflects multiple dimensions such as lack of awareness regarding appropriate health practitioners and discrimination by the qualified professionals. Other underlying reasons for this include the lack of public hospitals providing these services and the unaffordable costs of surgeries. A study participant has also revealed being comfortable getting the surgery done by the ‘guru’ . Moreover, the distance between their households and healthcare facility makes it inaccessible for them.

Health system barriers

Both transgender persons and healthcare providers reported a lack of knowledge of any insurance schemes specifically for transgenders or insurance coverage for the minority population under the available schemes. Their awareness regarding the inclusion of gender-specific needs such as sexual reassignment surgeries or hormonal therapies in the existing insurance schemes was limited.

The study participants also addressed the need for the inclusion of a third gender column in the patient information / outpatient cards across all the hospitals. This is in alignment with the Transgender Persons (Protection of Rights) Bill, 2019, which prohibits discrimination against them in healthcare [ 5 ]. It would also lead to a transgender-inclusive environment in the hospital and greater acceptance by other people.

TG participant 7 “ Whenever we go to the hospital, we are asked whether to write male or female. There is no option of transgender in the OPD cards.”

In India, nationally recognized identity cards are being provided by the Ministry of Social Justice and Empowerment as a step towards mainstreaming their identity. One participant revealed that recently when she visited a hospital, the authorities denied accepting the TG identity card. This incident reflects the need of generating awareness across all sectors, including healthcare, to prevent the exclusion of transgender people in society.

TG participant 8 I had fever for a few days, I went to a hospital for treatment. I gave my transgender ID card issued by the ministry. They said this is not valid.

Accessibility

Majority of the participants revealed having negative experiences in healthcare settings. They reported that they had to wait very long to access health services.

One participant complained about the long counselling procedure and time to access hormone replacement therapy. Furthermore, many qualified practitioners discourage and demotivate the use of hormones. This reluctance among medical practitioners to prescribe hormones often compels transgenders to refer to the unfiltered content on the internet, resulting in the self-administration of hormones. Since transgenders are unaware of the side effects of unregulated dosages of hormones, it can result in adverse health outcomes.

Sometimes, the health facilities with available resources are situated far away from the residence of transgenders leading to difficulty in access. In one of the key informant interviews, a medical practitioner shared her experience with a transgender patient whose vaginal canal got stenosed as a complication of post Sex Reassignment Surgery (SRS). Since the health facility was around 500 km from her hometown, she could not reach the hospital on time.

Availability

One of the most significant barriers to healthcare reported by transgenders was a dearth of healthcare providers trained to address their specific health problems. Healthcare providers also emphasized the need for training to understand the best practices for their care. Some parts of clinical training should also include the importance and impact of physician-patient communication. The use of correct pronouns should be taught to collect sufficient and accurate information on their gender identity and thus, making the hospital settings friendly for them. Additionally, awareness sessions should also be conducted for medical professionals to make them comfortable and culturally competent while dealing with this section of society.

Some participants also shared that there is a need for designated facilities in healthcare, such as separate queues in OPDs and dedicated wards or beds in hospitals. It was felt that these facilities’ absence contributed to their fear and delay in access and utilization of desired appropriate care. Due to contributory social factors, such as real or perceived stigma, it is challenging for them to accommodate within the general ward. Medical providers had contrasting views in lieu of the unavailability of designated facilities. While most believed that providing separate queues and beds for them in hospitals was essential, one of the doctors felt this would promote social exclusion.

TG participant 1 Where should we stand in hospitals? Queues made for males or females? Separate beds shall be assigned for us so that we can access the services without hesitancy or fear of discrimination . HCP-3 Providing them separate facilities for all services cannot be the ultimate solution. Will this promote equity or rather advance social exclusion? We should think about it.

Moreover, there is a lack of specialist care in hospitals that are accessible to them. There is no provision to address transgender-specific health problems at the primary healthcare level. Lack of robust referral mechanisms leading to delayed or denied care was also reported.

Affordability

Transgenders are not registered and do not have access to benefits under the insurance schemes functioning in the country. All hospitals in the country do not provide gender transition services. Those services provided by the private sector often have charges beyond their paying capacity. As a result, accessing and affording healthcare becomes a challenge for them. This is one reason that urges them to go to unqualified traditional medical practitioners for gender transitioning surgeries or ‘Dai Nirwan.’

Breast augmentation is another common procedure utilized by transgenders. One participant discussed the availability of various implant materials and how their costs vary depending on the quality. Additionally, due to financial reasons and lack of awareness, low-quality implant materials are utilized in surgeries, which increases their risk for breast cancer.

Social barriers

The non-medical factors play a crucial role in impacting health outcomes. Addressing social determinants is central to reducing existing health inequities. In this study, all the participants reported stigma and discrimination while sharing their experiences in healthcare settings. They further added that this discouraged them from utilizing available health services.

The participants reported that even the healthcare providers were uncomfortable with their presence and did not treat them like other patients.

Poor housing conditions and lack of job opportunities further push them into this vicious cycle of stigma and sickness. Transgenders have also reported experiencing psychological distress due to a lack of social support. Positive attitude and gender-supportive relationships in society can promote their well-being. The need for their inclusion in society through awareness generation by government initiatives was emphasized.

TG participant 3 We can promote family planning through condom advertisements, so why not involve transgender figures in government health awareness advertisements and campaigns .

Healthcare provider expertise in TG health

All the healthcare providers felt the need for training to improve physician-patient communication and transgender persons care. A culturally competent healthcare perspective is fundamental for treating the transgender population. Those providers who had experience with such patients were more likely to provide perspectives on their care and barriers than those who had never encountered such cases. They highlighted that very few transgender patients are registered in the hospitals of Rajasthan. This can be attributed to the stigma associated with their presence rather than assuming they do not wish to seek healthcare services.

This study sought to investigate and fill the gap in the domain of transgender healthcare. The purpose of the research was to characterize the health needs and barriers faced by transgender individuals in navigating through the health system. Previous international and Indian studies have reported a lack of transgender-sensitive care. The findings of this research corroborate this premise. There is a wide and serious gap between the population’s needs and the healthcare system’s ability to respond to these needs.

The socio-demographic profile of the participants in this study revealed that the income of the majority of the participants was below INR 10,000. This finding is in alignment with the results (70%) of a study conducted among transgenders in Vadodara, Gujarat, India [ 12 ].

The FGD gave an opportunity to the study participants to express their general and gender-specific health needs. The health needs of the participants in this study included available medical services common to the general population and certain specific transgender needs, particularly psychiatric support, hormonal therapies, and sex-reassignment surgeries. This is in accordance with the previous studies, which also identified general health problems that need to be addressed, including the high prevalence of diabetes and hypertension, substance abuse, anxiety, and depression [ 13 ].

Transgender individuals discussed a range of experiences and barriers encountered in the healthcare system in accessing the available services. The barriers were categorized at the healthcare system, social and individual levels. The system-level barriers ranged from policy issues to hospital or organizational problems. It included a lack of coverage for the transgender population in government health insurance schemes. The introduction of a comprehensive package master in the Ayushman Bharat scheme has now addressed the lack of coverage for transgenders in the existing insurance schemes. It includes the existing packages as well as specific packages for transgenders [ 14 ]. This paves the way for a new chapter in their care. The unavailability of trained healthcare providers is another major problem. In 2019, National Medical Commission (NMC) updated the medical education curriculum and added a new module on Attitude, Ethics, and Communication (AETCOM) competencies [ 15 ]. It could be used as an opportunity to introduce culturally sensitive communication training for medical professionals, especially focusing on LGBTQ + community, to advance our aim to achieve equity. In addition to the unavailability of trained doctors, the inaccessibility of healthcare facilities and unaffordability also negatively impact the people’s health. All these underlying factors contribute to their practice of getting surgeries done by traditional and untrained medical practitioners. These findings are consistent with another study conducted in India to assess the health-seeking behavior of transgender people. They also reported long waiting times in hospitals affecting their health behaviors and are confirmed to have undergone medical procedures performed by gurus or technicians [ 16 ].

The finding of concern that emerged in our study sample was the use of unprescribed hormone therapy. This finding is similar to a study conducted in Maharashtra to assess the practices related to hormonal therapy [ 17 ]. It states that participants reported going for unsupervised hormone replacement therapy due to unaffordability, lack of trained healthcare providers and prior experiences in healthcare settings [ 17 ]. In order to avail the hormonal therapy, transgender patients require to undergo psychological counseling’s for confirmation of gender dysphoria. In our study, transgender individuals felt that the psychotherapy sessions are too long, leading to a delay in the initiation of hormone replacement therapy. World Professional Association for Transgender Health (WPATH) mentioned in their Standards of Care (SOC) that any minimum number of sessions cannot be fixed and is an individualistic approach. It depends whether someone wishes to avail psychological support before, during, or throughout the transition process [ 18 ]. Gender transitioning may involve but not be limited to procedures such as hormonal therapy and sex reassignment surgeries. Moreover, there are only a few public health facilities providing gender-transition services and there is no government support in the form of subsidies to avail these services from a private hospital. The government, is however, working on extending and empaneling public and private hospitals in order to make these services accessible to the population.

This need assessment study also attempted to address the social determinants barring healthcare access. Stigma, discrimination, support from family and friends, and difficulty in seeking housing determine health and healthcare accessibility. These factors have also been highlighted by the study conducted in Vadodara, India [ 12 ]. It re-emphasizes the findings from our study that social determinants such as lack of economic and educational opportunities, rejection, and isolation from society have an impact beyond gender identity issues, rather, they pose a risk to the psychological status of the transgender population.

The health disparities and barriers to care faced by transgenders should be addressed to promote health equity and justice. Comprehensive approaches to improve access, utilization, and quality of healthcare services are currently lacking. These challenges can also be addressed at the following levels:

Individual Level.

Healthcare system Level.

Community Level.

Garima Greh facilities have been introduced as shelter homes for transgender individuals where basic amenities are being provided to them [ 19 ]. They can be utilized as launchpad sites to improve their awareness of their rights and available entitlements and medical interventions. IEC materials can be displayed at Garima Greh facilities for health promotion and modification of their health-seeking behaviors. Similar to ASHA workers who are community members working for their healthcare, volunteers can be appointed from their community. Training of these volunteers can be done (Training of Trainers) so that they can improve their health-seeking behavior, increase awareness, and aid in the overall empowerment of the community.

All hospitals and clinical settings shall provide a safe and welcoming environment for gender-diverse people [ 20 ]. The fact that their physical, mental, and cultural differences affect their behaviors must be known but, more importantly, understand these differences and assigning them value is the key. Actions can be taken to promote transgender identity across healthcare settings by displaying Information, Education and Communication (IEC) material regarding their health needs and promoting their acceptance in society – ‘This hospital is LGBTQIA + friendly.’ Transgenders can also be part of the healthcare system, whereby; they can act as resource persons and promote the inclusivity of gender-diverse individuals. Medical students shall be trained to communicate sensitively to the needs of transgenders, and doctors shall be trained in a culturally competent way to treat their gender-specific needs. To promote access and utilization of health services, specific transgender clinics are being set up across the country. All participants in the study felt this would help them to access available services without hesitancy. Separate general health camps for regular and dental check-ups can also aid in health promotion and equity. Another potential solution to promote transgender health is through digital solutions. Tele-consultation can be an effective way to address their needs as well as to protect them from social stigma and discrimination that hinder their access and utilization of available services.

According to World Health Organization (WHO), social determinants account for 30–55% of health outcomes [ 21 ]. The most effective way to address SDH is by action at the community level. General campaigns and community awareness sessions are essential to promote acceptance by the general population. Moreover, the study suggests that there is a need for awareness and sensitization of transgenders regarding the basket of medical options available for them such as techniques for fertility preservation.

In summary, the study demonstrates the health issues of transgenders and reflects upon the various factors influencing health and access to care. It urges the stakeholders to contemplate the need to safeguard the rights of transgenders by providing equitable access to the available resources.

This study is an attempt to explore health needs from beneficiary as well as service provider perspectives. Our findings are consistent with the previous literature. Findings from this study provide evidence base for future research and a helpful tool for the policymakers and advocates to better address the needs of transgender people.

The study’s major limitation was that only one focus group discussion was undertaken due to limited time and difficulty in accessing the desired population. However, one FGD allowed for exploration of issues related to transgender experiences and healthcare needs. It allowed the researchers to gather detailed narratives that might not emerge from individual interviews. Given the paucity of literature in the Western Indian context, a single focus group discussion can be valuable for informing advocacy efforts and policy reforms. Participants in the study were recruited through purposive sampling and did not differentiate between cultural identities of transgender persons; therefore, the results might vary geographically and according to the social context, thus, limiting the external validity. The health needs might vary between transgender male and female populations, but there was only one transgender male participant in our study. Additionally, the service providers’ knowledge was not directly assessed by explicitly questioning the standards of care.

Proposed framework

Based on study findings, a Gender Responsive Healthcare System Framework is designed. (Fig.  2 ) This framework illustrates and emphasizes on the need for planning, interventions, and actions at 3 levels – policy (a), health system (b), social, and individual (c) in alignment with the identified themes represented in Table  1 . The framework describes how the barriers can be addressed at these 3 levels to have a robust and gender-responsive healthcare delivery system in India.

The concept of healthcare is multi-dimensional. Combined action is required at the administrative, service provider and beneficiary level for a gender responsive healthcare system. Inclusion of the transgender population in existing health insurance schemes is central to reducing their out-of-pocket expenditure and helping them gain recognition in the society through the treatments that they wish to access. Outpatient cards in hospitals should include options of male, female and transgenders/others (gender diverse) creating a safe and welcoming environment. Existing health programs shall also target transgender population for reducing the burden of infectious diseases such as tuberculosis and non-communicable diseases. At the healthcare system level, medical professionals competent to provide transgender specific care and availability of specialists shall be ensured. A robust referral mechanism from primary healthcare centers to higher levels could ensure uninterrupted care for the transgender population. Moreover, hospitals have distinct queues, for men and women. There is a need to understand that gender is not a visibly readable or unchanging phenomenon, rather it is a social construct. Proper queue management can address not only the issues of stigma, but also make healthcare accessible to them. At an individual level, good health seeking behavior and familial support can aid in improving health outcomes. Altogether, these efforts at the policy, health system and individual level can lead to improvement in accessibility, availability, affordability and acceptability of services by the transgender people.

Gender Responsive Healthcare System Framework

This study has explored experiences of transgender people navigating through the healthcare system. These accounts have highlighted their health needs and the barriers they face in accessing care. They expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified ranging from absence of targeted policies to individual behavior. Targeted efforts and intersectoral collaboration are required for effective establishment and delivery of healthcare services.

Data availability

The data generated and reviewed are fully available in this article and its supplementary files. For any further data, Dr. Tanvi Kaur Ahuja ([email protected] could be contacted).

All relevant data analyzed during this study are included in this published article and its Supplementary Information files.

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Acknowledgements

The authors would like to acknowledge the contribution of Sambhali trust, Jodhpur and Nai Bhor Sanstha, Jaipur for helping us to get in touch with the transgender participants.

This research received no funding.

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School of Public Health, All India Institute of Medical Sciences, Jodhpur, India

Tanvi Kaur Ahuja, Akhil Dhanesh Goel, Manoj Kumar Gupta, Nitin Joshi, Annu Choudhary, Swati Suman, Kajal Taluja & Pankaj Bhardwaj

Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India

Akhil Dhanesh Goel, Manoj Kumar Gupta & Pankaj Bhardwaj

Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur, India

Madhukar Mittal

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, India

Navdeep Kaur Ghuman

Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, India

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Contributions

T.A., A.G. Conceptualized the research study done, A.G., M.G., N.J., P.B. framed the Methodology was framed, T.A., N.K., M.M., N.S., N.G., A.C. contributed in collection of data; T.A., A.G. prepared the Original draft; T.A., A.G., S.S., K.T. Reviewed and edited the manuscript; P.B. M.G., N.J. Supervised the research study, All authors have read and agreed to the published version of the manuscript.

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Correspondence to Tanvi Kaur Ahuja or Akhil Dhanesh Goel .

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The study was approved by the Institutional Review Board in July 2022. The certificate reference number granted by the Institutional Ethics Committee is AIIMS/IEC/2022/4023. Informed consent was taken from all participants who agreed to participate in the study. Participants were informed that they could withdraw consent to participate at any time during the interview. All methods were performed in accordance with the relevant guidelines and regulations.

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Ahuja, T.K., Goel, A.D., Gupta, M.K. et al. Health care needs and barriers to care among the transgender population: a study from western Rajasthan. BMC Health Serv Res 24 , 989 (2024). https://doi.org/10.1186/s12913-024-11010-2

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Received : 29 May 2023

Accepted : 18 April 2024

Published : 26 August 2024

DOI : https://doi.org/10.1186/s12913-024-11010-2

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