Gender-affirming surgeries may be added to Medicare – but the evidence is still being reviewed

For the first time in Australia, an independent committee is considering whether Medicare should fund gender-affirming surgery for trans adults (those aged 18 and over).

Gender-affirming surgery is any surgical procedure that helps trans and gender-diverse (trans) people align their bodies with their gender. For example, a double mastectomy can create a masculine-appearing chest.

Having better gender alignment (sometimes called “congruence”) allows trans people to feel more like themselves. The evidence shows it has significant benefits for body image, wellbeing, quality of life and mental health.

Not every trans person wants surgery (or hormone therapy). But new Medicare items would allow those who can afford private health insurance to receive up to 75% in rebates for certain procedures. Surgeries are not currently available in the public system.

The Medical Services Advisory Committee is currently considering an application by the Australian Society of Plastic Surgeons for about 30 new Medicare items. Some authors of this article were part of a group which supported preparation of the application. The committee will assess whether the items are effective and whether they are value for money.

However, earlier this month the committee said it needed more evidence before making a decision on funding. Specifically, it is seeking more information about the long-term impact of surgery on trans adults.

What does gender-affirming surgery involve?

Procedures can include chest, genital, facial and voice surgery. These can be complex and require multiple operations.

For example, phalloplasty is a procedure that creates a penis using tissue from the arm, leg or abdomen. It can involve several separate procedures, including shaping the penis, allowing urination while standing and sometimes creating a scrotum.

Each surgery has a long recovery, which may require leave from work and/or caring duties. Like all surgeries, gender-affirming surgeries also have some risks, including infection, blood clots or poor healing.

We don’t have data about how many people have gender-affirming procedures in Australia. But research from the United States shows the average age for first surgery is 29.

Guidelines from the World Professional Association of Transgender Health do not recommend any gender-affirming surgery before the age of 16.

Why do people get gender-affirming surgery?

The positive impact on trans people’s mental health and wellbeing can be substantial.

For many trans people, simply leaving the house may mean being called by the wrong name or pronouns, being treated unfairly or facing violence. Australian research show one-third have faced discrimination when seeking employment and more than 60% have experienced verbal abuse.

Surgeries such as facial feminisation – reshaping the brow or jaw bones to create a more traditionally feminine appearance – can change the experience dramatically.

Having surgery can reduce distress about the mismatch between someone’s body and their gender (gender dysphoria), increase confidence and help people blend in. This can improve their physical safety and reduce harassment.

Surgery is also linked to lower suicide risk. Conversely, not being able to access surgery increases the risk of suicide attempts and limits social participation including employment.

This makes access not just a matter of choice, but a crucial equity issue.

How do people pay for surgery now?

Access to surgery in Australia remains extremely difficult due to cost, lack of surgeons, and no public hospital services. This means there is significant unmet need.

For example, one Australian study found 63% of trans people recorded male at birth wanted facial feminisation surgery, but only 6% had had it. Trans people who want gender-affirming surgery but haven’t had it yet have a 71% higher chance of reporting a suicide attempt.

At present, most Australians pay out-of-pocket or travel overseas to have the surgery with costs ranging from A$20,000 to more than $100,000.

Some people are so desperate to access surgery they drain their superannuation. This can increase financial insecurity for people who are already at higher risk of economic disadvantage.

The cost of surgery may also mean people forgo essentials such as healthy food or social connection, adding to health risks.

Do people regret surgeries?

The Medical Services Advisory Committee has acknowledged a clear unmet need for subsidised gender-affirming surgery. But it has asked for stronger evidence, including on rates of regret after having a procedure.

Contrary to common misconceptions, regret is very rare. Less than 1% of people decide it was the wrong choice to undergo gender-affirming surgery and even fewer request surgery to return their body to what it was (so-called “detransition”).

Some studies show the proportion of people who regret surgery is higher after a knee operation (10%) or cancer procedure (24%) than gender-affirming surgery.

As with all surgery, good information beforehand and shared decision-making between the patient and their health-care team improves satisfaction and reduces regret.

So, what is the review still considering?

There have been more than 2,700 public submissions to the review, with more than 92% in favour of public funding. The evidence highlights the low regret rates after surgery and the benefits for mental health.

The Medical Services Advisory Committee has requested further work over two stages.

The first stage is an assessment of the evidence on clinical outcomes to understand:

• how international guidelines may apply in Australia
• long-term benefits of surgery
• complication rates from surgery, such as urinary problems or infections
• the best ways to support people before and after surgery.

If the committee finds surgery to be helpful and safe, the second stage will assess whether Medicare funding is value for money. This will weigh up the upfront costs of subsidising surgery against gains such as better mental health, reduced suicide risk and workforce participation.

What happens next

A decision is not anticipated for at least another year or more. If approved, new Medical Benefits Scheme items would mean Medicare rebates for gender-affirming surgeries, though some out-of-pocket costs will likely remain.

Medicare rebates won’t eliminate all barriers, such as the lack of surgery being performed in public hospitals. But it is a valuable first step towards recognising gender-affirming surgery as part of essential health care – and lives may depend on it.