The legal status of gender-affirming surgery and gender-affirming hormone therapy varies by jurisdiction, often interacting with other facets of the legal status of transgender people. Key considerations include whether people are allowed to get such surgeries, at what ages they are allowed to if so, and whether surgeries are required in order for a gender transition to be legally recognized. As of 2007[update], the countries that perform the greatest number of gender-affirming surgeries are Thailand and Iran.[1]
Sex reassignment surgery is allowed and can be performed in the country after obtaining approval from Al-Azhar Mosque or the Coptic Orthodox Church of Alexandria.[3][4][5]
Medical procedures for trans people in Ethiopia are illegal. Gender expression out of the 'norm' faces major issues in violence and social stigmatisation.[6]
Casablanca, Morocco, is notable for being the home of Clinique de Parc, Georges Burou's clinic for transgender women. Burou is considered one of the pioneers of gender-affirming surgery.[7] A French gynecologist, Burou created the anteriorly pedicled penile skin flap inversion vaginoplasty, still considered the "gold standard" of skin-lined vaginoplasty.[8] He is credited with having performed over 3000 vaginoplasties in 1973.[9]
Medical procedures such as hormone replacement and gender-affirming surgeries are illegal in Nigeria. Additionally, it is not possible to change one's name or gender marker in the country of Nigeria, and trans individuals in Nigeria are not legally protected for gender expression.[10][11]
Trans and gender diverse peoples are protected and acknowledged under South African law, where no sterilisation or other forced procedures are necessary to have legal recognition of a person's gender identity. Gender-affirming surgery is legal and accessible, but not covered by medical aid.[12]
Gender-affirming surgeries and changing one's legal name and gender are all accessible in the People's Republic of China, but there are rigorous steps to follow to do so. To change one's legal gender, they must show a gender determination certificate as proof of gender-affirming surgery, which cannot be undergone without: psychiatric diagnosis, verification of no prior criminal record, proof that the family has been notified, written agreement from their family and work unit, that they are unmarried and over 20 years old. The psychiatric diagnosis is not given to someone who is not exclusively heterosexual.[10]
Transgender people in India need to undergo a gender-affirming surgery to change their legal gender from male to female or vice-versa. This has been opposed by Indian transgender activists.[13] India also requires proof of having undergone a gender-affirming surgery for changing the gender listed on one's passport. This requirement has been challenged in courts.[14] The government's flagship national health insurance scheme may soon cover gender-affirming surgeries for transgender individuals.[15] India is offering affordable gender-affirming surgeries to a growing number of medical tourists[16] and to the general population.[17]
In Indonesia, it has been possible to undergo gender-affirming surgery since 1973. Vivian Rubianti was the first transgender woman to have legal gender changes in the country. Indonesia requires gender-affirming surgery and judicial approval for a person to legally change gender.[citation needed]
The Iranian government's response to homosexuality is to endorse, and fully pay for, gender-affirming surgery.[18][19] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring gender-affirming surgery permissible for "diagnosed transsexuals".[18] Eshaghian's documentary, Be Like Others, chronicles a number of stories of Iranian gay men who feel transitioning is the only way to avoid further persecution, jail, or execution.[18] The head of Iran's main transsexual organization, Maryam Khatoon Molkara, who convinced Khomeini to issue the fatwa on transsexuality, confirmed that some people who undergo operations are gay rather than transsexual.[1] According to the research study of Zara Saeidzadeh who questioned fourteen trans men, nine had completed their medical transition and the remaining five had the intention of completing their medical transition.[20]
In October 2023 the Supreme Court unanimously ruled to no longer require sterilization for legal gender change and requested a lower court to review the requirement of gender-affirming surgery.[21]
The first gender-affirming surgery in Singapore was successfully performed on 30 July 1971. Singapore was the first country in Asia to legalize gender-affirming surgeries in 1973. Singapore's first gender-affirming operation on a transmasculine patient took place three years later, and was carried out in three stages between August 1974 and October 1977, as gender-affirming surgeries for transmasculine people are much more complex. Medical tourism for such surgeries are also prevalent in Singapore as local hospitals also accepts foreigners. In 1996, the Singaporean government legalized marriage for transsexuals.[23]
Since 2016, France no longer requires gender-affirming surgery as a condition for a gender change on legal documents.[25][26] In 2017, a case brought earlier by three transgender French people was decided. France was found in violation of the European Convention on Human Rights for requiring the forced sterilization of transgender people seeking to change their gender on legal documents.[27]
Psychiatric evaluation is necessary to receive a diagnosis of "transsexualism" before one can be authorized for hormone therapy or gender-affirming surgeries in Russia. Neither hormone replacement therapy nor gender-affirming surgeries are covered by the Federal Compulsory Medical Insurance Fund.[29]
Despite a resolution from the European Parliament in 1989 suggesting advanced rights for all European Union citizens, as of 2002 only Andalusia's public health system covers gender-affirming surgery.[30][better source needed][needs update]
In 2010, Switzerland's Federal Supreme Court struck down two laws that limited access to gender-affirming surgery. These included requirements of at least 2 years of psychotherapy before health insurance was obligated to cover the cost of gender-affirming surgery[31][32] and inability to procreate.[33]
In 2015, the Administrative District Court of Kyiv, Ukraine, ruled that forced sterilization was unlawful and no longer required for legal gender change.[citation needed]
The minimum age for gender-affirming surgery varies from 16 in Scotland to 17 in England and 18 in Wales.[34] It is not a requirement for legal gender change.[35]
On 4 June 2008, MINSAP, the Cuban Ministry of Public Health, issued Resolution 126 – which resulted in all aspects of transition related healthcare being covered for Cubans under Cuba's public healthcare system. Cuba was the first country in Latin America to do so.[39][40] Prior to being approved, it was suggested that the bill would make Cuba the most progressive nation in Latin America on gender issues.[41] The resolution was heavily pushed for by CENESEX a government-funded body dedicated to advocating LGBT rights and sexual diversity.[39][42]
As of a 2014 law,[44]Mexico City no longer requires gender-affirming surgery for changes of gender on birth certificates, and several states have followed suit.[45][needs update]
Some U.S. states treat gender-affirming as a prerequisite for recognition of a legal sex change on official documents such as passports, birth certificates, or IDs, and historically (prior to the legalization of same-sex marriage) for marriage licenses.[citation needed]
Alabama and Arkansas passed laws in 2022 and 2021, respectively, that prohibit gender-affirming surgery and hormonal treatment for minors. Plaintiffs have challenged the legislation in Alabama, and a May 2022 federal court injunction blocked enforcement of the law while litigation is pending. Implementation has been challenged in state, and then federal court also in Arkansas, delaying implementation, as of January 2023.[46][47] An estimated 9,000 gender-affirming surgeries take place annually in America.[48]
As of November 2023[update] twenty-two states have banned gender-affirming medical care for people under 18 years old, including twenty-one states that have specifically banned or restricted hormonal treatment in addition to surgery.[49]
At the same time, many Democrat-controlled states have gone in the opposite direction and enacted laws protecting access to gender affirming care for minors and adults. These laws, often called "shield" laws, often explicitly combine protections for gender-affirming care and abortion and cover a variety of protections including protecting both providers and patients from being punished, mandating insurance providers to cover the procedures and acting as "sanctuary states" that protect patients traveling to the state from other states that have banned such treatments among other things.[50] As of November 2023, 14 states and the District of Columbia have enacted "shield" laws.
In 2012, Argentina began offering government subsidized total or partial gender-affirming surgeries to all persons 18 years of age or older.[51][52][19] Private insurance companies were prohibited from increasing the cost of gender-affirming surgery for their clients. At the same time, the Argentinian government repealed a law that banned gender-affirming surgery without authorization from a judge.[53] It is not required for Argentines to undergo gender-affirming surgery to change gender on legal documents.[54]
Dr. Roberto Farina performed the first male-to-female gender-affirming surgery in Brazil in 1971.[55]
In March 2018, Brazil's Supreme Court unanimously removed medical and judicial criteria for all trans persons to change their names and legal gender.[10] Trans people in Brazil can receive government funded hormone replacement therapy at the age of 16, and gender-affirming surgery at the age of 18.[56] Brazilian civil registry offices recorded 3,165 gender affirming surgeries in 2022.[57]
In 2012, a bill was introduced in Chile that stated gender-affirming was no longer a requirement for legal name change and gender recognition.[58] In 2013, Chile's public health plan was required to cover gender-affirming surgery.[58] The cost is subsidized by the government based on a patient's income.[58][needs update]
In Colombia, gender marker changes are often granted only[vague] when a medical precondition is met, including, but not limited to, psychiatric diagnosis or sterilisation. Gender-affirming surgery is not always necessary[vague] for gender change but it is still available under Colombian insurance or if paid out of pocket.[59]
Although gender-affirming surgeries are available, trans people in Peru often face barriers to gender-affirming care (e.g., lack of qualified and willing providers, high cost, restrictive gatekeeping in assessment for hormones and surgery), and trans individuals may face malpractice and various forms discrimination.[60]
The Comprehensive Law for Trans People (La Ley Integral para Personas Trans), which was passed on 19 October 2018, improves the access of surgeries for transgender people in Uruguay. It says that the state will pay for them. For those under 18 wishing to undergo surgery, a request to change their legal name and gender must accompany their registration. For minors who do not have consent from guardians, judicial authorization may be sought in its place.[61]
^"Ethiopia". Human Dignity Trust. 15 February 2019. Archived from the original on 21 April 2022. Retrieved 17 April 2022.
^Hage, J.J.; Karim, R.B.; Laub, D.R. (December 2007). "On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca". Annals of Plastic Surgery. 59 (6): 723–9. doi:10.1097/01.sap.0000258974.41516.bc. PMID18046160. S2CID25373951.
