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For Laurel Hubbard and other transgender athletes, change is finally coming to Olympics

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Reporters from around the world showed up hours early, waiting in line for a chance to interview Laurel Hubbard. Now, as she made her way into the mixed zone, the room where athletes answer questions after competition, the assembled media leaned close and held out tape recorders to catch every word.

It did not matter that the New Zealand weightlifter had just missed on all three of her snatch attempts. It did not matter that she was the first athlete eliminated from the evening session of the super-heavyweight division.

A representative from the New Zealand team accompanied Hubbard into the room and announced that she would make a brief statement and would not be taking any questions. The 43-year-old rarely speaks publicly.

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Still, reporters wanted to hear what she had to say.

With a baggy gray sweatshirt draped over her large frame and a brown baseball cap tugged down over dark hair, Hubbard spoke into a microphone.

“Sport is something that all the people around the world can do,” she said. “It’s inclusive, it’s accessible and I think that’s just, just really fabulous.”

Everyone listened because on Monday night at the Tokyo International Forum, Hubbard became the first openly transgender athlete to compete in an individual sport at the Olympics.

The Tokyo Games are setting a precedent. Though Hubbard is widely considered the first, she is not alone.

BMX rider Chelsea Wolfe arrived in Japan as an alternate on the U.S. women’s freestyle team. Quinn, a Canadian soccer player making their second trip to the Olympics, recently came out as transgender nonbinary — a person who neither identifies exclusively as male or female.

Change has not come easily.

“A big cultural war has erupted around this,” said Tom Farrey, executive director of the Sports & Society Program at the Aspen Institute. “I think it’s a conversation that has a lot to do with issues that go well beyond sports to how we organize our society.”

The International Olympic Committee first allowed transgender athletes in 2004 but only if they had undergone sexual reassignment surgery. None showed up.

Revised IOC guidelines in 2015 placed no restriction on athletes who transition from female to male. For male-to-female cases, officials drew a line between the sexes — anyone wishing to compete as a woman had to register below a maximum testosterone level or, if above, had to take medication to alter their body chemistry.

“These are really hard discussions because the science gets murky,” said Mark Dyreson, a sports historian at Penn State. “It keeps changing and evolving.”

Though much of the scientific community believes testosterone is the primary reason for the performance gap between men and women in many sports, some remain skeptical. Critics note that the hormone occurs naturally in both men and women.

“It’s not possible to make the flat-footed statements that people want to make about the relationship between testosterone and athleticism,” Katrina Karkazis, an Amherst College professor of sexuality, women’s and gender studies, said in a 2019 interview. “It’s far more complicated.”

Research has identified other factors, including gonads, secondary sex characteristics and internal genitalia. Individual athletes may respond differently to testosterone based on hormone receptors.

There is another facet of this issue that affects women with what officials call a “difference of sexual development,” meaning their body chemistry does not fit established definitions.

Caster Semenya of South Africa won the women’s 800 meters at the last two Olympics but was barred from Tokyo when international track officials lowered the testosterone limit in 2018. Her case has proceeded through several unsuccessful appeals and is now before the European Court of Human Rights.

“This fight is not just about me, it’s about taking a stand and fighting for dignity, equality and the human rights of women in sport,” Semenya posted on social media earlier this year. “All we ask is to be able to run free as the strong and fearless women we are!!”

The transgender athletes in Tokyo all met the testosterone standard. They began drawing attention in the spring as Hubbard moved closer to Olympic qualification and, again, when sprinter CeCe Telfer was not allowed to run the women’s 400-meter hurdles at the U.S. Olympic trials.

More recently, Wolfe was criticized for an alleged social media post involving the U.S. flag. Quinn talked about a new sense of pride on the soccer field.

“I feel sad to know there were Olympians before me unable to live their truth because of this world,” Quinn said in Tokyo. “I feel optimistic for change. Change in legislature, change in rules, structures and mindsets.”

Through her teens and early 20s, Hubbard competed in men’s weightlifting and rose to a national level in New Zealand. She quit at 23 for reasons beyond sport.

“It just became too much to bear,” she told New Zealand public broadcast service RNZ. “But the world has changed, of course, and I feel like I’m now in a place where I can train and compete and cope with all of that. Just the pressure of trying to fit into, perhaps, a world that wasn’t really set up for people like myself.”

Transitioning at 35, she resumed lifting and, after more than a decade away from the sport, began competing as a woman. A silver medal at the 2017 world championships was followed by gold at the 2019 Pacific Games.

“I’m not going to say it wasn’t hard,” she told the New Zealand Herald in 2017. “You would have to be a robot to not be affected by some of that and what people were saying. But I can’t control what other people think, what they feel, what they believe and I’m not going to try.

“All I can do is lift to the best of my ability and then let whatever happens, happen.”

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This spring, she qualified for one of five spots on the New Zealand women’s team headed for Tokyo.

“I am grateful and humbled by the kindness and support that has been given to me by so many New Zealanders,” she said in a statement, using the Indigenous Māori language in adding that “your support, your encouragement, and your aroha [love] carried me through the darkness.

“The last 18 months has shown us all that there is strength in kinship, in community, and in working together towards a common purpose.”

Social media responded with both praise and predictable vitriol. Television personality Piers Morgan lashed out on the “Good Morning Britain” show: “Are you happy for anyone born to a male biological body to simply raise their hand without any need for surgery and to compete in the Olympics against women born to female biological bodies?”

Anna Vanbellinghen, a Belgian weightlifter, said that while she supports the transgender community, she considered it “a bad joke” that Hubbard would be allowed in the women’s draw.

“I am aware that defining a legal frame for transgender participation in sports is very difficult since there is an infinite variety of situations, and that reaching an entirely satisfactory solution, from either side of the debate, is probably impossible,” Vanbellinghen told insidethegames.com . “However, anyone that has trained weightlifting at a high level knows this to be true in their bones: This particular situation is unfair to the sport and to the athletes.”

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When others in Hubbard’s division were asked about competing against her, U.S. lifter Sarah Robles declined to comment and Wenwen Li of China said: “I just respect the rules.” It was impossible to know if it was resentment or, like golfers asked about Tiger Woods, they were simply tired of talking about her.

Some critics have suggested that growing up male gives transgender athletes an unfair advantage even after they transition. Asked about fairness at a news conference in Tokyo, the IOC’s medical and scientific director referenced the effects of feminizing hormone therapy.

“There is a lot of research to ascertain the residual advantage of going through male puberty,” Richard Budgett said. “But you have to weigh that against all the other disadvantages of going through transition. It is not something any individual would take lightly.”

IOC president Thomas Bach reiterated that classifying athletes by gender is complex.

“This is a question that has no one-size-fits-all solution,” he told reporters. “This is a question which differs from sport to sport.”

Olympic officials anticipated the scrutiny Hubbard would face in Tokyo.

At the weightlifting venue, they stocked the media workroom with cards containing a QR code for information on covering LGBTQ athletes. Budgett offered words of encouragement.

“Laurel Hubbard is a woman and is competing under the rules of her federation,” he said. “We have to pay tribute to her courage and tenacity in qualifying for the Games.”

Unlike other athletes from her country, she was not made available at pre-competition news conferences. New Zealand team officials wanted to be careful about access.

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“We are working really closely with Laurel, as we do with any athlete, but particularly because of the huge focus on her,” said Ashley Abbott, the team’s director of communications. “We will continue to work with her and make sure she is supported at all times and has got an understanding about what the environment might be like.”

Maybe nothing could have prepared her for what awaited Monday night.

So many reporters showed up that venue managers started a waiting list for the mixed zone, hoping to trim the crowd. Extra seating had to be opened up in the auditorium.

Hubbard started with a miss at 120 kilograms (264 pounds), letting the bar slip away. On her second try, she raised 125 kilograms (275 pounds) over her head but judges ruled that she did not have control. Her third attempt, at the same weight, was not to be.

Lingering for a moment onstage, she made a “heart” symbol with her hands, smiled and waved.

Later, talking to reporters, she apologized for her performance and gave thanks to everyone who had supported her career. That included the people of New Zealand and the IOC which, she said, “reaffirmed their commitment to the principles of Olympism.”

“I know that my participation at these Games has not been entirely without controversy,” she said. “But they have been just so wonderful.”

With that, Hubbard said “Thank you” and walked away.

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Yes, Caitlyn Jenner Revealed She Had Gender-Affirming Surgery, But It's No One's Business

By Nicole Kwan

In the nearly two years since Caitlyn Jenner first went public with her gender identity, she’s been upfront with her struggles as a transgender role model and advocated for transgender students . In her new book, The Secrets of My New Life (out April 25), she opens up about undergoing gender-affirming surgery, Radar Online reports . However, experts say it’s important to remember that what transgender individuals—or any individuals—do or don’t do with their bodies isn’t anyone else's business but their own.

Jenner says she underwent the surgery in January 2017, calling the surgery a “complex decision” because of the health risks of the operation.

“I am telling you because I believe in candor,” she explains in the book. “So all of you can stop staring. You want to know, so now you know. Which is why this is the first time, and the last time, I will ever speak of it.”

She goes on to add that a penis “has no special gifts or use to me other than what I have said before, the ability to take a whiz in the woods. I just want to have all the right parts. I am also tired of tucking the damn thing in all the time.”

According to the Encyclopedia of Surgery , an estimated 100 to 500 gender-affirming surgeries are performed in the U.S. each year, but since many surgeries are performed in private facilities with no reporting requirements, statistics are hard to obtain. The Mount Sinai Center for Transgender Medicine and Surgery performs about three male-to-female gender-confirming surgeries a week (156 a year), Jess Ting, M.D., lead surgeon at the center, tells SELF. Marci Bowers, M.D., a transgender obstetrician and gynecologist in Burlingame, California, tells SELF that she performs about 140 male-to-female surgeries a year.

Jenner’s choice to undergo the surgery is her decision and one that every transgender person has the right to make on his or her own. The reality star has the luxury of resources and finances, but all transgender individuals face a range of options—and challenges —when it comes to how they transition.

These options can be broadly categorized into:

Social: This choice involves how individuals would like their gender expression to be recognized in public. Choices can include asking to be called by a certain name and pronoun , as well as the type of clothing you wear.

Legal: Individuals may choose to change their assigned name and sex on their birth certificate and other identification, such as a driver's license and passport.

Medical: Individuals have the option to undergo hormone therapy for the development of male/female secondary sex characteristics.

Surgical: Individuals can pursue surgical intervention for the purpose of masculinization or feminization.

“Transitioning is a very personal thing. It can look like a lot of different combinations of [options]. They’ll choose the options that best fit them,” Dane Menkin, CRNP, the clinical operations manager at Mazzoni Center Family & Community Medicine in Philadelphia, tells SELF. He notes that safety is a big factor when it comes to a person’s transition choices, “especially in the climate we’re in now. If you don’t pass well enough to be in whatever bathroom people deem you should be in, your safety is in jeopardy.”

Some trans individuals choose none of these options. “It’s important to recognize that there are people who make decisions to be their authentic selves, and they don’t want any intervention that involves anybody but themselves. They never set foot in an office like mine,” Menkin says. “There’s no less validity to their gender identity.”

The cost—financially and personally—of gender-affirming choices is prohibitive for many. Trans individuals risk losing their jobs, disrupting their relationships with their families and partners, and more, Andrew Goodman, M.D., AAHIVS, associate director of medicine at Callen-Lorde Community Health Center in New York City, tells SELF. “We’re lucky in New York state that many insurance companies cover hormone therapy and surgery. Many people in many other states don’t have access to that care and can’t afford it,” he says. “If you’re really poor, you don’t have the money to go to court and make a legal name change. If you’re living in a 40-year relationship with a spouse who loves you and doesn’t want you to leave or isn’t ready or willing to do this with you, you may only make private changes like only wearing [gender-expressing] clothing on vacation,” Menkin says. (Coverage for gender-affirming surgery varies by state and insurance plan. The Human Rights Campaign has resources for understanding trans health-care access.)

Male-to-female genital reconstruction, or penile inversion vaginoplasty, involves taking the penis and scrotum and reconstructing them into a vagina , clitoris, urethra, labia minora, and labia majora. “It’s a difficult and complicated multistep surgery and involves multiple organs, the urinary system, skin, nervous system, and blood vessels,” Ting says. “The operation is also aesthetically challenging because we want the vagina to be functional—so the patient can have receptive penetrative sex and be able to have orgasms .” At Mt. Sinai, the surgery involves a plastic surgeon, a urologist, and a gynecologist and is done in three to four hours, but Ting notes that it can take six to eight hours at other centers.

Recovery is painful, Ting says, and patients can’t be active and must be careful with even walking because of the tension at the surgery site. Health risks for male-to-female genital reconstruction include bleeding, poor wound healing, and development of a rectovaginal fistula, which occurs when a hole is accidentally made in the rectum and, if untreated, passed stool can exit through the vagina. This condition is rare and usually correctable, Ting says. One of the big downsides to the operation, he adds, is the maintenance of the newly created vagina, which includes daily dilation for a year to ensure the organ doesn’t shrink.

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Among those who choose to undergo surgery, experts say it’s more common for transgender individuals to have chest reconstruction (also referred to as “top surgery”), which can include breast implants or partial mastectomy, than genital reconstruction. Female-to-male genital reconstruction (metodioplasty) is less common and more complicated than a vaginoplasty, Ting says. All that being said, surgery is by no means a requirement or expectation of trans individuals. “There are plenty of people who don’t want to have these surgeries done for their own reasons, and that’s fine. We definitely support people for whom that’s the case,” Goodman says.

It’s important to remember that, like with any celebrities and their aspirational lives, they can be an inspiration for us, but they’re not setting the rules or the norm. “When we have visibility with people like Caitlyn Jenner, Laverne Cox , and Chaz Bono, we see a lot of people who have been able to and desired to complete all aspects of transition," Goodman says. “Many people don’t have the desire to complete all those aspects or for many reasons are unable to.”

Individuals' gender identity and gender expression are theirs and theirs alone. What's in someone else's pants or dress shouldn't matter to anyone else. Or as Menkin puts it: “Unless you are sleeping with someone or medically taking care of their genitalia, it doesn’t matter what’s behind their zipper."

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Caitlyn Jenner Confirms Gender Reassignment Surgery in ’20/20’ Interview

Next question, please! Caitlyn Jenner confirmed during a wide-ranging 20/20 interview with Diane Sawyer on Friday, April 21, that she underwent gender reassignment surgery, but didn’t want to say too much about the procedure itself.

“I’m not going to dwell on that subject,” the former Olympian, 67, told Sawyer, 71. “It’s not an appropriate question to ask a trans person.” Jenner did, however, reveal that she went under the knife this past January.

Related: Caitlyn Jenner's Best Style Moments: Photos!

The reality star clarified that even though she opted to undergo the surgery and decided to write about it in her new memoir, she “wasn’t less a woman the day before I had the surgery than the day after the surgery, because that did not define who I am as a human being.” Rather, she said, what makes a woman a woman is “what’s between your ears.”

“I’ve grown into Caitlyn,” she continued. “It’s tough to take 65 years of being Bruce and being male, and then, like, overnight, everything changes. At first you don’t know how to handle it.”

Jenner came out as transgender in April 2015, and made headlines a few months later, in June 2015, when she covered Vanity Fair wearing a strapless white bodysuit.

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“I know my kids, they thought, You know what, it’s a little too much,” she said. “But, from my standpoint, I had suffered for 65 years. To have a beautiful shot of my authentic self was important and [I wanted] the shock value. I wanted to end the old Bruce, my old life, and that picture did it.”

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Jenner shares two daughters, Kylie and Kendall Jenner , with ex-wife Kris Jenner , and helped raise Kris’ four kids from her previous marriage to Robert Kardashian — Kourtney , Kim , Khloé and Rob . But she admitted in the 20/20 interview that she’s become “distant” from some members of the Kardashian clan. The LGBT spokeswoman also has four other children ( Brody , Brandon , Cassandra and Burt ) from her first two marriages.

Related: Kardashian Family Album

Overall, however, Jenner said that she feels “happy” with where she’s at. “[There is] peace in my soul,” she told Sawyer. “All that confusion has left me.” Jenner’s memoir, The Secrets of My Life , is out Tuesday, April 25.

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Why Caitlyn Jenner Decided to Undergo Sex Reassignment Surgery

Jenner confirmed the surgery in her new book,  The Secrets of My Life

Elizabeth Leonard is Managing Executive Editor and West Coast Bureau Chief for PEOPLE, where she's worked in leadership positions across the brand's entertainment and human interest verticals for 25 years.

Caitlyn Jenner has undergone a physical milestone in her transition.

In her new memoir, The Secrets of My Life , the gold medal-winning Olympian–who confirmed her transition from male to female and revealed her new identity as Caitlyn in June 2015–says that she underwent gender reassignment surgery in January 2017, PEOPLE has confirmed.

“The surgery was a success, and I feel not only wonderful but liberated,” she writes in the memoir, according to RadarOnline , calling the decision to undergo the surgery “complex.”

Jenner says she decided to be open about the surgery in order to stop the questions and inquiries about when — or if — she would have it done.

“I am telling you because I believe in candor,” she says. “So all of you can stop staring. You want to know, so now you know. Which is why this is the first time, and the last time, I will ever speak of it.”

RELATED VIDEO: Caitlyn Jenner Considered Sex Change in 1985, Ex-Wife Linda Thompson Reveals

“I just want to have all the right parts. I am also tired of tucking the damn thing in all the time.”

“Gender confirmation surgery is something I think anybody in my position, or the girls’ position, of course you look into,” Jenner previously said of undergoing the surgery on a 2016 episode of I Am Cait . “For me, I have no idea what the future holds.”

In October 2016, Jenner legally changed her name to Caitlyn Marie and her gender to female.

The Secrets of My Life is available April 25 .

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'20/20' Recap: Caitlyn Jenner confirms she underwent 'final surgery' in gender reassignment

FILE: Caitlyn Jenner told Diane Sawyer that she had undergone "the final surgery" in her gender reassignment procedures (Reuters)

Caitlyn Jenner told Diane Sawyer that she had undergone "the final surgery" in her gender reassignment procedures on Friday night's "20/20" special.

The former Olympian previously known as Bruce confirmed in her book "The Secrets of My Life," coming out on Tuesday, that the 2017 "surgery was a success."

And Jenner said on the ABC interview, she had "no regrets, none whatsoever."

Beyond that, Jenner didn't want to talk about the details, telling Sawyer, "I’m not going to dwell on that subject. It's not an appropriate question to ask a trans person."

But nothing else was off-limits, as Sawyer caught up with Jenner nearly two years after the TV journalist had done their last emotional interview. Then, the ex-athlete stunned the world by revealing how he had lived a lie. Inside, ex-decathlon champ Jenner had always identified as a woman.

Since then, Jenner said she has been "happy, peaceful…all of that confusion has left me….I did the right thing" -- and doesn't miss "Bruce" a bit.

Sporting red nails and stylishly feminine clothing, Jenner recalled how—when he was still known as Bruce--he had put an instruction in his will: "When I'm buried, I want to be dressed as her 'cause that's the way I'm going to heaven."

As many know from her former reality show, "I Am Cait," Jenner is a Republican and she confided to Sawyer, "Yes, I did vote for Trump."

Jenner was initially impressed with Trump for reaching out to transgender people at the Republican National Convention and noted, "He wanted me to come play golf with him."

But Jenner got upset when President Trump's administration revoked the federal guidelines that allowed public school students to use bathrooms corresponding to their gender identity--believing it's an issue best left to state and local authorities to decide.

"It was extremely disappointing…you mess with my community, you don't give us equality and a fair shot, I'm coming after you," Jenner sighed about President Trump's decision.

Although Jenner has had her jawline, forehead, and breasts worked on, she insists she's always been a woman because what's important is "what's between your ears."

Jenner said she's fine with her ex-wife, Kris Jenner, and stays in touch with all her kids while they pursue their own lives.

"Nobody calls that much. I reach out to them," commented the former "Keeping Up with the Kardashians" star.

Jenner told Sawyer that she has "never been on a date" in the two years since she came out as transgender, and doesn't really see dating in her future.

Instead, Jenner is most focused on helping the transgender community through charities and building awareness about discrimination and other issues.

"I want to fight this fight," she vowed.

For more on Caitlyn Jenner, tune in to Tucker Carlson on Monday night for his exclusive interview with the star. It will be Carlson's first time in his new 8 p.m. EST slot. 

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Caitlyn Jenner Reveals She’s Had Gender Reassignment Surgery in New Memoir

Much of Caitlyn Jenner ’s transition has been up for public consumption, but the Olympian managed the seemingly impossible: She underwent gender reassignment surgery in January of this year, and nobody suspected a thing until she revealed it to the world herself.

Jenner, 67, shares and bares all in her upcoming memoir, The Secrets of My Life , due out April 25 — and it’s there that she talks about the experience for what, she writes, will be the first and last time.

“I just want to have all the right parts. I am also tired of tucking the damn thing in all the time,” she explains, adding that she was excited to realize she’d be living authentically for the first time in her life. “The surgery was a success, and I feel not only wonderful, but liberated.”

She continues, “I am going to have an enthusiasm for life that I have not had in 39 years since the Olympics, almost two thirds of my life.”

In the book excerpt obtained by RadarOnline.com , Jenner reveals she finally made the full transition after being annoyed by fans asking intrusive questions about her genitals. But that doesn’t mean fans have the right to continue to pester her about it. As she says in the book, “You want to know, so now you know. Which is why this is the first time, and the last time, I will ever speak of it.”

Jenner’s upcoming tome netted a huge advance — $4 million, to be exact — and she worked on it with Friday Night Lights author Buzz Bissinger, who also wrote the Vanity Fair profile that introduced Caitlyn to the world . Jenner’s life has certainly exploded since she revealed her transition to Diane Sawyer on 20/20 just two years ago this month.

“For all intents and purposes, I am a woman,” she told Sawyer. “My brain is much more female than it is male. That’s what my soul is. Bruce lives a lie. She is not a lie. I can’t do it anymore.”

Which is why gender reassignment was a natural next step. As Jenner continued to embrace her new form, she found she had no use for anything that was associated with her old self. As she writes about the choice to undergo surgery, “So why even consider it? Because it’s just a penis. It has no special gifts or use for me other than what I have said before, the ability to take a whiz in the woods.”

Of course, the more public aspect of Jenner’s transition from Bruce to Caitlyn continued long after her interview with Sawyer, including her groundbreaking Vanity Fair cover story and photo shoot in June 2015, which Jenner likened to being better than winning a gold medal. She became active on Twitter soon afterward, and now boasts nearly 4 million followers. That July marked the debut of her E! reality show, I Am Cait , which was canceled after two seasons. Jenner officially changed her name in September 2015.

Previously, Jenner was reluctant to discuss gender reassignment — even going so far as to shoot down any comments on it in her Sports Illustrated appearance last June . “It’s nobody’s business whether I want to do that to my body,” she told SI . But she did admit that “Little Caitlyn” had been inside her since her youth, and it took a long time for her to come to terms with it.

“Sometimes she raised her cute little head more than others. I was female inside, but I wasn’t an effeminate male. So I could hide easily in the male world,” Jenner said of that period of her life. “My life was distraction after distraction after distraction. Being a macho male was a way for me to try to convince myself that the woman living inside of me really isn’t living inside me.

“It disgusted me,” Jenner said of her male body. “I was big and thick and masculine. The rest of the world thought it was this Greek god kind of body. I hated it. But it’s what I was given, so I just tried to do the best I could with it.”

But now that she’s undergone gender reassignment surgery, Jenner can truly live freely as her authentic self. Congratulations, Caitlyn! Now let’s respect her wishes and never speak of this again.

Read more from Yahoo Celebrity :

Mandy Moore’s Best Childhood Throwbacks

‘Cosby’ Star Keshia Knight Pulliam Reflects on Her ‘Hell of a Year’

Mariah Carey and Bryan Tanaka End Their (Maybe Fake) Relationship

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FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media  claims only 1% of people regret their gender-affirmation surgery.

  View this post on Instagram   A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Jazz Jennings Says She Is 'Super Happy With The Results' Of Her 3rd Gender Confirmation Surgery

Jazz experienced complications after her initial procedure.

• Jazz Jennings says she is "super happy with the results" of her third gender confirmation surgery in an Instagram post and in the new season of I Am Jazz .
• Jazz, 19, has had a difficult surgical course and experienced complications after her initial surgery.
• Gender confirmation surgery can help give transgender individuals the appearance and functional abilities of the gender they identify as.

Now, Jazz has good news for her fans and followers: surgery number three is complete. She shared a smiling photo of herself in a hospital gown in bed. Jazz explained why she's smiling in the Instagram caption: "I’m feeling so great after completing my third surgery! This third procedure was for cosmetics, and I’m super happy with the results. Thank you to everyone who has followed my journey and supported me along the way❤️💕"

Her family has been by her side through each surgery. Her brother Sander Jennings commented on her photo: "Although this surgery was one of the scariest moments of my life, I am so glad I was there to stick by your side the entire way 😊👏🏻"

Back up...when did Jazz's surgery ordeal begin?

TLC star Jazz Jennings revealed back in June 2018 that she was preparing to undergo gender confirmation surgery. Her TLC show, I Am Jazz , follows her throughout her journey.

Jazz was assigned male at birth but identifies as female . She had her first gender confirmation surgery in 2018, and told ABC News that this was something she'd wanted for a long time. “This is a moment that I had always envisioned and just experiencing it was so surreal," she said. "I was like, I can’t believe this is happening.”

Jazz said her surgeon also requested that she lose 30 pounds before going under the knife. “That was really, really challenging because I had an addiction to food,” she said. “And it was something that gave me comfort. And I had to let that go because the surgery is so much more important to me than any slice of cake or pizza.”

She previously opened up to ABC News about her gender confirmation surgery and revealed that the process wasn’t exactly seamless. Season five revealed that Jazz's surgery was a bit more complicated than others (Jazz hadn't gone through puberty because of hormone blockers, so she didn't have enough penile skin to create a vagina).

Despite a longer-than-usual surgery (hers took double the time of a typical gender confirmation procedure), Jazz's surgery went well, according to Newswee k . "It's better than what I hoped for," said Jess Ting, MD, Jazz's doctor.

But the real reveal happened when Jazz finally saw her new vagina for the first time—on TV, no less. "Oh my god, that's crazy," she said. "It's a pretty vagina!" Jazz also had to learn how to use her new vagina, telling her family “I don’t think I know how to pee!”

Jazz experienced complications soon after her first surgery.

Everything seemed fine, but a few days later, Jazz started having complications. "Her wounds were definitely separating and a blood blister began to form," her mom Jeanette said. Jazz’s doctor recommended that she go back to the OR for more surgery.

In season five episode five, Jazz was wheeled off into surgery with her mom in the waiting room, according to Newsweek . It turns out, Jazz was taken into surgery at just the right time, according to Dr. Ting. "As I was getting her on the bed, I heard something go pop," he said. "When I looked, the whole thing had split open. If we hadn't done it today, in the OR, it would've happened in the hotel."

Jazz was in the hospital for 10 more days after that, until she was finally discharged. But it took another 13 days for her doctor to determine that she was okay to fly back home. "I'm just so excited, I'm very, very homesick," Jazz said. "I can finally move forward in the healing process."

Jazz goes through even more procedures during season 6 of her show.

The sixth season I Am Jazz, which is airing Tuesdays on TLC, continues to document Jazz's transition and all of its ups and downs.

In the season premiere, Jazz undergoes a corrective surgery on her clitoris .

Jazz shared her own perspective on Instagram and opened up in the caption: "As portrayed in this teaser, the past year has been extremely challenging. I have experienced some of my highest highs and lowest lows... Although it continues to be difficult to cope with the hurdles life throws my way, I have been actively working every day to get better and improve my mental health."

Earlier this year, she showed off her scars in swimsuit photos on Instagram . Jazz shared the big reveal for the #decadechallenge on New Year's Day. In the photos, she's wearing a maroon one-piece swimsuit and her scars on her upper thighs are clearly visible. She wrote in the caption: "These are my scars on full display in #2019. I'm proud of my scars and love my body just the way it is. I call them my battle wounds because they signify the strength and perseverance it took to finally complete my transition❤️#decadechallenge."

Okay, tell me more about gender confirmation surgery.

Gender confirmation surgery is a surgical procedure that can help "give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be," according to the American Society of Plastic Surgeons (ASPS).

For a male-to-female transition, gender confirmation surgery may include facial surgery, top surgery (to construct and shape breasts) and/or bottom surgery, to reconstruct male genitalia to female genitalia, according to the ASPS. What kind of surgery a person gets depends on their specific desires, and not all transgender people choose to have surgery, according to GLAAD .

Jazz previously revealed on her YouTube channel that she was having a vagina constructed, which is called transfeminine bottom surgery. The surgery transforms existing male genitalia and reconstructs it into female genitalia, the ASPS says.

Since Jazz began transitioning at a young age and never went through puberty, her procedure was slightly different. At age 11, Jazz had a hormone blocker implanted in her arm to hinder the growth of her penis, according to the Daily Mail .

Because she didn't develop fully as a male, there wasn't wasn’t enough tissue in her genital area to construct a vagina. Instead, she likely underwent an “experimental” procedure that involved taking out her her peritoneal lining (a thin membrane that surrounds her stomach) to build the vaginal canal—something she discussed on YouTube in May before her surgery.

“I’m going to have new genitalia…like penis to vagina…that’s some serious sh*t, y’all,” she said in the YouTube video.

Jazz, whose third and possibly fourth gender confirmation surgeries will be covered even more in season six of her show, I Am Jazz , told ABC News that she saw her surgery as the end of her transition. “I’ve gone through the whole medical process, and this is really the last thing that will validate my identity as a woman,” she said. “There is nothing else after this. I just get to be myself, be in the body that I’ve always wanted. And then I can live my life as just Jazz.”

Jennifer Nied is the fitness editor at Women’s Health and has more than 10 years of experience in health and wellness journalism. She’s always out exploring—sweat-testing workouts and gear, hiking, snowboarding, running, and more—with her husband, daughter, and dog. 

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New Hampshire teen one of the youngest to have gender reassignment surgery

by Kenneth Craig

A high school student in New Hampshire is being called a 'pioneer' after becoming one of the youngest people to undergo gender reassignment surgery. But her long and challenging journey began when she was just a child.

At 17 years old, Emily Tressa finally feels fully herself. Last month, she became one of the youngest patients in the country to undergo gender reassignment surgery. Emily says, "For me, it feels almost like I'm finally fully complete now."

Emily was born a boy, but says she always knew she was a girl. "I used to look in the mirror and be like, is it only me? Am I the only one that feels like this? That I'm trapped in the wrong body?"

As a young child, she changed her name and started dressing as a girl. First at home and later at school. With her parents support, and under the care of doctors and psychologists, Emily eventually started taking hormone blockers to prevent male puberty and then estrogen to develop a female body.

Dr. Jess Ting is director of surgery at Mount Sinai Center for Transgender Medicine and Surgery. He says, "Emily is a pioneer because she is at the forefront of this new generation of young kids, adolescents who are realizing what they are much earlier in life and are able to transition even before puberty."

Dr. Ting performed Emily’s reassignment surgery at Mount Sinai Hospital in New York. He created female anatomy that is fully functional.

His team has completed 12-hundred various operations. Dr. Ting considers it a life saving surgery, given the alarming rates of attempted suicide among transgender youth.

Emily's mother, Linda, says her only fear is what would happen if she tried to hold Emily back. “We saw the unhappy boy and we saw the happy girl. And we knew the statistics and we knew we'd much rather have an alive daughter than a dead son.”

Emily has become an activist and uses social media to let others know they're not alone. She says, "I don't want people to feel like that. It's OK to be who you are and just present to the world as yourself."

Experts say there are still many barriers for transgender people when it comes to accessing appropriate care and that contributes to long-term health problems. Recently, the American College of Physicians published new guidelines for doctors to help them better understand medical issues specific to this population.

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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

State health plans must cover gender-affirming surgery, US appeals court rules

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Brendan Pierson reports on product liability litigation and on all areas of health care law. He can be reached at [email protected].

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Toddlers can’t get gender-affirming surgeries, despite claims

FILE - People attend a rally as part of a Transgender Day of Visibility, Friday, March 31, 2023, by the Capitol in Washington. The Associated Press on Friday, April 21, 2023 reported on social media users falsely claiming a map shows the states where it’s possible for a 3-year-old child to receive gender-affirming surgery. (AP Photo/Jacquelyn Martin, File)

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CLAIM: Map shows the states where it’s possible for a 3-year-old child to receive gender-affirming surgery.

AP’S ASSESSMENT: False. The map shows which states have passed or are considering anti-transgender laws. Children as young as 3 are not qualified to undergo operations to change their gender, medical experts say. Nationally-recognized medical guidelines recommend patients be at least 15 years old to receive the surgeries, and only then in special circumstances.

THE FACTS: Social media users are sharing a map of the U.S. that purports to show which states are the hardest and which are the easiest to obtain sex change surgery for children as young as 3.

The map shows blue-colored states located mostly along the coasts and the Great Lakes and red-colored states that are mostly in the Midwest and South.

“The dark red states are where it’s hardest to get your 3 year old a sex change operation,” the text above the map claims.

“If you’re thinking about moving this could be helpful,” wrote an Instagram user who shared the map in a post that’s been liked nearly 280,000 times as of Friday. “Get away from the blue.”

But the map is being misrepresented online: it categorizes states according to the type of transgender laws or bills that have been enacted or are under consideration.

Red-colored states are those with the “worst anti-trans laws” while those in blue are the “safest states with protections” for transgender individuals, according to the map’s key, which is visible in small text in the bottom right corner of the image.

Erin Reed, a transgender advocate who developed the map, confirmed to The Associated Press that her graphic is being misrepresented.

She created the “Anti-Trans Legislative Risk” map to track bills moving through state houses across the country, and posted the latest version on her Substack page in March.

“In reality, this is MY map,” Reed later tweeted , sharing a screenshot of the false claim circulating online and adding a large red ‘x’ through it. “It evaluates the risk of anti-trans laws pulling people’s medical care, bans from bathrooms, and more.”

Reed also stressed that sex change operations aren’t permitted on 3 year olds.

“Gender affirming care starts with puberty blockers around age 11-14, and will progress to hormone therapy, with surgeries held off until later,” she wrote in an email to the AP.

Medical experts and LGBTQ advocates agreed, noting that such surgeries aren’t offered until a patient becomes a legal adult, though exceptions are made for minor teens who meet certain criteria.

“The general recommendation is for gender affirming surgeries to be done after age 18 with limited exceptions,” Dr. Michael Irwig, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, wrote in an email. “The patient should always be of an age where they have adequate maturity including the ability to understand the potential risks and benefits of any treatment.”

The World Professional Association for Transgender Health, a global group that sets standards for medical care of trans youths and adults, recommended last year that hormone treatment start no earlier than 14 years old and surgeries be offered only in rare exceptions in persons as young as 15. Both minimum ages were lower than prior recommendations.

Gender-affirming surgery includes a wide range of procedures, from plastic surgery to change facial features to so-called “top surgery” to change the chest or torso and so-called “bottom surgery” to make changes to genitals.

Teens who are 16 to 17 years old are generally limited to receiving only “top surgeries,” and they must be “consistent and persistent” in their gender identity for years, take gender-affirming hormones for some time and have approvals from both their parents and doctors, according to Aryn Fields, a spokesperson for the Human Rights Campaign, an LGBTQ advocacy group based in Washington, D.C.

“In all cases, gender affirming surgeries are only performed after multiple discussions with both mental health providers and physicians (including endocrinologists and/or surgeons), to determine if surgery is the appropriate course of action,” she wrote in an email.

This is part of AP’s effort to address widely shared misinformation, including work with outside companies and organizations to add factual context to misleading content that is circulating online. Learn more about fact-checking at AP .