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Gender-Affirming (“Sex Change”) Surgery

1. What is gender-affirming surgery?

Gender-affirming surgery (GAS) refers to medical procedures that alter sexual characteristics to match a person’s gender identity (their internal sense of being male, female, or another gender).

Common procedures include:

• Chest surgery (mastectomy or breast augmentation)
• Genital surgery (vaginoplasty or phalloplasty)
• Facial or voice surgery

These procedures are usually part of treatment for gender dysphoria, a condition where a person experiences distress because their gender identity differs from the sex assigned at birth.

2. How common is transgender identity?

Estimates vary by country and methodology.

Typical estimates:

• ~0.3–0.6% of adults identify as transgender in many Western surveys.
• Only a small fraction undergo surgery; many only use hormone therapy or social transition.

Example:

• In a large insured population study in the U.S., about 5.3 surgeries per 100,000 adults per year were performed. 

3. Age of people who undergo surgery

Research across hundreds of studies shows:

• Average age ≈ 30–35 years for people undergoing surgery. 
• Median age around 28–33 years in several clinical cohorts. 

Examples by procedure:

• Mastectomy: ~28 years
• Phalloplasty: ~33 years
• Vaginoplasty: ~35 years 

Most people:

• start hormone therapy around 31–32 years on average in one U.S. clinical sample. 

Minors undergoing surgery are rare, especially genital surgery. 

4. Sexual orientation of transgender people

Sexual orientation and gender identity are separate concepts.

Transgender people can be:

• heterosexual
• gay/lesbian
• bisexual
• queer
• asexual

In one clinical sample of transgender patients seeking surgery:

• Many transgender women were attracted to men, but others were attracted to women or both. 

Overall, research finds sexual orientation among transgender people is diverse, and many identify as non-heterosexual compared with the general population.

Key point:

• Being transgender does not mean a person is gay.

5. Regret after surgery

One of the most studied questions.

Large systematic reviews find:

• About 1% regret rate across multiple studies with thousands of patients. 
• Another systematic review found 1.94% regret. 

In the meta-analysis of 7,928 patients:

• 77 reported regret (~1%). 

Reasons for regret may include:

• poor surgical outcomes
• difficulty adapting socially
• lack of family or societal acceptance 

Some studies show regret rates lower than many other elective surgeries.

6. Detransition (reversing transition)

Not all regret results in reversal.

Examples from surveys:

• About 8% of transgender people report having detransitioned at some point, but most cases are temporary. 
• Reasons include:
  • social pressure
  • family rejection
  • discrimination
  • financial issues

Only a small fraction seek surgical reversal.

7. How many people truly feel they are the “wrong gender”?

The medical diagnosis used is gender dysphoria.

Research suggests:

• persistent gender dysphoria occurs in a small percentage of the population (well under 1%).
• diagnosis requires:
  • persistent identity mismatch
  • distress or impairment
  • evaluation by clinicians.

However, motivations for transition can vary:

• relief of dysphoria
• identity expression
• psychological wellbeing.

8. Countries performing the most surgeries

Precise global numbers are difficult because reporting is inconsistent.

However, major centers and countries include:

High-volume countries

1. United States
2. Thailand
3. Brazil
4. European countries (Germany, Netherlands, Spain)

Example research data:

• In one systematic review dataset:
  • 3,673 procedures in the U.S.
  • 514 in Europe
  • 97 in Asia (mainly Thailand)

Thailand is especially well-known due to:

• specialized surgeons
• medical tourism
• relatively lower costs.

9. Trends

Gender-affirming surgeries have increased significantly:

• Procedures increased over 150% in some years in the U.S. 
• Overall numbers nearly tripled from 2016–2020. 

Most common surgeries:

1. Chest surgery
2. Genital reconstruction
3. Facial feminization or other procedures

10. Key conclusions

Research generally finds:

• Transgender identity occurs in less than 1% of the population.
• The average surgical patient is about 30–35 years old.
• Regret rates are around 1–2% in large reviews.
• Sexual orientation among transgender people is diverse.
• The U.S. and Thailand are among the largest providers of surgery.