define the term gender reassignment

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What does it mean for someone to have the protected characteristic of “gender reassignment” under the Equality Act 2010? The government, public bodies, many employers and even employment tribunals are often confused about this.

Having the protected characteristic of gender reassignment does not mean that someone’s sex has changed or give them the right to make other people pretend that it has. 

These FAQs cover the definition of the characteristic and who it covers – and what this means for employers and service providers. 

Download these gender reassignment FAQs as a PDF.

What is the protected characteristic of “gender reassignment”?

What does it mean to have this characteristic , who can have this characteristic , does having the protected characteristic of gender reassignment mean that a person must be treated as the opposite sex , does the equality act outlaw “misgendering”, is it harassment to “out” a person as transgender , can employers have policies which require people to refer to transgender people in particular situations in a particular way , what should employers and service providers do to avoid the risk of harassment claims , should schools have rules about “misgendering”.

The Equality Act 2010 at Section 7 defines the protected characteristic of “gender reassignment” as relating to a person who is: 

“proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex.”

The law refers to this as being “transsexual”. But the term more commonly used today is “transgender” or “trans”. This broadly relates to anyone at any stage of a personal process. For example:

• A man tells his employer that he is considering “transitioning” and is seeing a therapist with the potential result of being referred for medical treatment.
• A man identifies as a “transwoman” without having any surgery or treatment.
• A woman identified as a “transman” for several years and took testosterone, but has now stopped and “detransitioned”.

The Equality Act protects people from direct and indirect discrimination, harassment or victimisation in situations that are covered by the Equality Act, such as in the workplace or when receiving goods or services.

Direct discrimination

Direct discrimination is when you are treated worse than another person or other people because:

• you have a protected characteristic
• someone thinks you have that protected characteristic (known as discrimination by perception)
• you are connected to someone with that protected characteristic (known as discrimination by association).

For example: an employee tells their employer that they intend to transition. Their employer alters their role against their wishes to avoid them having contact with clients.

The comparator is a person who is materially similar in other aspects but does not have the protected characteristic (“is not trans”). 

Indirect discrimination

Indirect discrimination happens when a policy applies in the same way for everybody but disadvantages a group of people who share a protected characteristic, and you are disadvantaged as part of this group. This is unlawful unless the person or organisation applying the policy can show that there is a good reason for the policy. This is known as objective justification .

For example: an airport has a general policy of searching passengers according to their sex. Everyone travelling needs to follow the same security procedures and processes, but it makes transgender travellers feel uncomfortable. This could be indirect discrimination, so the airport reviews its policy and changes it so that any passenger may ask to be searched by a staff member of either sex and have a private search, out of view of other passengers. 

Harassment is unwanted behaviour connected with a protected characteristic that has the purpose or effect of violating a person’s dignity or creating a degrading, humiliating, hostile, intimidating or offensive environment.

For example: a transgender person is having a drink in a pub with friends and is referred to by the bar staff as “it” and mocked for their appearance.

Victimisation

Victimisation is when you are treated badly because you have made a complaint of gender-reassignment discrimination under the Equality Act or are supporting someone who has made a complaint of gender-reassignment discrimination. For example:

For example: a person proposing to undergo gender reassignment is being harassed by a colleague at work. He makes a complaint about the way his colleague is treating him and is sacked.

The Equality Act also provides that if a person is absent from work because of gender-reassignment treatment, their employer cannot treat them worse than they would be treated if absent for illness or injury. 

Does a person have to be under medical supervision?

No. This was explicitly removed from the definition in 2010. Gender reassignment can be a personal process. 

Must they have a gender-recognition certificate or be in the process of applying for one?

No. The protected characteristic is defined without reference to the Gender Recognition Act.

Do they have to have made a firm decision to transition? 

No. Protection against discrimination and harassment attaches to a person who is proposing to undergo, is undergoing or has undergone a process (or part of a process).

During the passage of the Equality Act, the Solicitor General stated in Parliament: 

“Gender reassignment, as defined, is a personal process, so there is no question of having to do something medical, let alone surgical, to fit the definition. “Someone who was driven by a characteristic would be in the process of gender reassignment, however intermittently it manifested itself.  “At what point [proposing to undergo] amounts to ‘considering undergoing’ a gender reassignment is pretty unclear. However, proposing’ suggests a more definite decision point, at which the person’s protected characteristic would immediately come into being. There are lots of ways in which that can be manifested – for instance, by making their intention known. Even if they do not take a single further step, they will be protected straight away. Alternatively, a person might start to dress, or behave, like someone who is changing their gender or is living in an identity of the opposite sex. That too, would mean they were protected. If an employer is notified of that proposal, they will have a clear obligation not to discriminate against them.” 

In the case of Taylor v Jaguar Land Rover , a male employee told his employer that he was “gender fluid” and thought of himself as “part of a spectrum, transitioning from the male to the female gender identity”. He said to his line manager: “I have no plans for surgical transition.” He started wearing women’s clothing to work, asked to be referred to by a woman’s name and raised a question about which toilets he should use. The Employment Tribunal concluded that he was covered by the protected characteristic. 

Can children have the protected characteristic? 

Yes. In the case of AA, AK & Ors v NHS England , NHS England argued that children who are waiting for assessment by the Tavistock Gender Identity Development Service (GIDS) do not have the protected characteristic as they have not yet reached the stage of proposing to transition. The Court of Appeal rejected this argument. It noted that the definition of “gender reassignment” does not require medical intervention and can include actions such as changing “one’s name and/or how one dresses or does one’s hair”.

The court concluded:

“There is no reason of principle why a child could not satisfy the definition in s.7 provided they have taken a settled decision to adopt some aspect of the identity of the other gender.”

It noted that the decision did not have to be permanent. 

Is “Gillick competence” relevant to the protected characteristic?

No. “Gillick competence” refers to the set of criteria that are used for establishing whether a child has the capacity to provide consent for medical treatment, based on whether they have sufficient understanding and intelligence to fully understand it.

Having the protected characteristic of gender reassignment (that is, being able to bring a claim for gender-reassignment discrimination) does not depend on having any diagnosis or medical treatment. Therefore Gillick competence is not relevant to the Equality Act criteria. 

No. There is nothing in the Equality Act which means that people with the protected characteristic of “gender reassignment” need to be treated in a particular way, or differently from people without the characteristic. 

Article 9 and 10 of the European Convention of Human Rights protect the fundamental human rights of freedom of speech and freedom of belief. 

In the case of Forstater v CGDE [2021] it was established that the belief that men are male and women are female, and that this cannot change and is important, is protected under Article 9 and in relation to belief discrimination in the Equality Act. 

This means that employers and service providers must not harass or discriminate against people because they recognise that “transwomen” are men and “transmen” are women. Employers and service providers cannot require people to believe that someone has changed sex, or impose a blanket constraint on expressing their belief. 

No. “Misgendering” is not defined or outlawed by the Equality Act. 

In general, people who object to “misgendering” mean any reference to a person who identifies as transgender by words that relate to their sex. This can include using the words woman, female, madam, lady, daughter, wife, mother, she, her and so on about someone who identifies as a “transman”, or man, male, sir, gentleman, son, husband, father, he, him and so on about someone who identifies as a “transwoman”. 

Any form of words may be harassment, but this depends on the circumstances and the purpose and effect of the behaviour. Harassment is unwanted conduct related to a relevant protected characteristic that has the purpose or effect of violating a person’s dignity, or creating an intimidating, hostile, degrading, humiliating or offensive environment for a person.   An employment tribunal would also consider:

• that person’s perception
• the other circumstances of the case
• whether it is reasonable for the conduct to have that effect.

Tribunals have emphasised that when judging harassment context is everything, and warned against a culture of hypersensitivity to the perception of alleged victims.

Employment tribunal judgments

As Lord Justice Nicholas Underhill found in Dhellwal v Richmond Pharmacology [2009], a case decided under the Race Relations Act:

“What the tribunal is required to consider is whether, if the claimant has experienced those feelings or perceptions, it was reasonable for her to do so. Thus if, for example, the tribunal believes that the claimant was unreasonably prone to take offence, then, even if she did genuinely feel her dignity to have been violated, there will have been no harassment within the meaning of the section.”

In the Forstater case, the employment appeal tribunal said that it was not proportionate to “impose a requirement on the Claimant to refer to a trans woman as a woman to avoid harassment”. It said that:

“ Whilst the Claimant’s belief, and her expression of them by refusing to refer to a trans person by their preferred pronoun, or by refusing to accept that a person is of the acquired gender stated on a GRC, could amount to unlawful harassment in some circumstances, it would not always have that effect. In our judgment, it is not open to the Tribunal to impose in effect a blanket restriction on a person not to express those views irrespective of those circumstances.”

In the case of de Souza v Primark Stores [2017] , a transgender claimant who went by the name of Alexandra, but whose legal name was Alexander, was found to have been harassed by colleagues who made a point of using the male form of name when they knew he did not want them to, but not by being issued with a “new starter” badge that showed his legal name. 

In the case of Taylor v Jaguar Land Rover [2020] , a male claimant who wore women’s clothing  to work was judged to have been exposed to harassment by colleagues saying “What the hell is that?”, “So what’s going on? Are you going to have your bits chopped off?”, “Is this for Halloween?” and referring to the claimant as “it”. 

Not necessarily. 

A person can be “outed” as transgender in two different ways: 

• Their sex is commonly known and recorded, but their transsexualism is not (for example a man who cross-dresses at the weekend and is considering transitioning is “outed” at work by someone who has seen them at a social event).
• They are disappointed in the expectation of being treated as one sex when they are actually the other (for example a person who identifies as a “trans woman” is referred to as male by a woman in a changing room).

In Grant v HM Land Registry [2011] , which concerned the unwanted disclosure that an employee was gay, Lord Justice Elias found that this did not amount to harassment: 

“Furthermore, even if in fact the disclosure was unwanted, and the claimant was upset by it, the effect cannot amount to a violation of dignity, nor can it properly be described as creating an intimidating, hostile, degrading, humiliating or offensive environment. Tribunals must not cheapen the significance of these words. They are an important control to prevent trivial acts causing minor upsets being caught by the concept of harassment.”

The perception (or hope) of transgender people that they “pass” as the opposite sex is often not realistic. Their sex is not in fact hidden, but is politely ignored by some people in some situations. It is not reasonable for them to be offended by other people recognising their sex, particularly if they are seeking access to a single-sex service. Acknowledging someone’s sex, particularly where there is a good reason, is unlikely to be harassment. 

In the first-instance case of Chapman v Essex Police , a transgender police officer felt embarrassed and upset when a police control-room operator double-checked his identity over the radio because his male voice did not match the female name that the operator could see. The tribunal did not uphold a complaint of harassment, finding that the claimant was “too sensitive in the circumstances”.

Yes, but those policies must be proportionate. Employers cannot have blanket policies against “misgendering”, but can have specific policies concerning how staff should refer to transgender people in particular situations. Organisations should recognise that these policies constrain the expression of belief, and therefore they should seek to achieve their specific aims in the least intrusive way possible.

When determining whether an objection to a belief being expressed is justified, a court will undertake a balancing exercise. This test is set out in the case of Bank Mellat v HM Treasury :

• Is the objective the organisation seeks to achieve sufficiently important to justify the limitation of the right in question?
• Is the limitation rationally connected to that objective?
• Is a less intrusive limitation possible that does not undermine the achievement of the objective in question?
• Does the importance of the objective outweigh the severity of the limitation on the rights of the person concerned?

For example: 

• A company provides a specialist dress service to transsexual and transvestites. The men who use the service expect to be called “she” and “her” and referred to as Madam. It is justified for the employer to train and require staff to use this language when serving customers. 
• Staff at a full-service restaurant greet customers as “Sir” and “Madam” as they arrive. The restaurant’s policy is that staff should use the terms which appear most appropriate based on gendered appearance, and to defer to customer preference if one is expressed. This is justified by the aim of creating the service and ambience that the restaurant owners seek to provide. 
• A public body assesses claimants for medical benefits, including individuals with mental-health conditions. It directs its staff to refer to claimants using the terms which the claimants prefer, including using opposite-sex pronouns when requested, in order to make them feel comfortable. However, it recognises that in recording medical information, assessors must be able to be accurate about claimants’ sex. This is justified by the aim of providing a service that is accessible and effective for vulnerable clients. 

The case of David Mackereth v AMP and DWP concerned a doctor who lost his job undertaking claimant health assessments for the Department for Work and Pensions because he refused to comply with its policy on using claimants’ preferred pronouns. The employer’s policy was found not to have amounted to unlawful harassment or discrimination against Dr Mackereth, in the particular circumstances of his job. However, the Employment Appeal Tribunal stated that “misgendering” would not necessarily be harassment: 

“Such behaviour may well provide grounds for a complaint of discrimination or harassment but, as the EAT in Forstater made clear, that will be a fact-specific question to be determined in light of all the circumstances of the particular case.”

Relevant considerations

In Higgs v Farmor’s School [2023] Mrs Justice Eady sets out the considerations that are likely to be relevant considering whether constraining the expression of a belief (“manifestation”)  in order to avoid harassment or discrimination is justified in the context of employment. These include:

• the content of the manifestation
• the tone used
• the extent of the manifestation
• the worker’s understanding of the likely audience
• the extent and nature of the intrusion on the rights of others, and any consequential impact on the employer’s ability to run its business
• whether the worker has made clear that the views expressed are personal, or whether they might be seen as representing the views of the employer, and whether that might present a reputational risk
• whether there is a potential power imbalance given the nature of the worker’s position or role and that of those whose rights are intruded upon;
• the nature of the employer’s business, in particular where there is a potential impact on vulnerable service users or clients
• whether the limitation imposed is the least intrusive measure open to the employer.

Employers cannot force employees to believe that people can change sex, or prevent them expressing that lack of belief except in limited circumstances. So what should employers do to protect transgender people from harassment, and themselves from liability? 

They should have ordinary policies against bullying and harassment, including jokes, name-calling, humiliation, exclusion and singling people out for different treatment.

They should seek to avoid putting people in situations they will reasonably experience as hostile or humiliating.

Ambiguous rules put people in situations where it is reasonable to feel offended. For example, an employer provides “female” toilets, showers and changing rooms, but allows some male staff in because they identify as transgender. This creates a hostile environment: 

• female staff are surprised, shocked, humiliated and upset to find themselves sharing with a colleague of the opposite sex
• male staff members who want people to treat them as women may be challenged or face comments that are intended to intimidate, humiliate or degrade them.

This was the situation faced by the Sheffield Hospital Trust , which had a policy that transgender staff could use opposite-sex facilities. It had to deal with the fall-out when women complained about seeing a half-naked male in their changing room and the male staff member sued for harassment after being questioned about this.

Rather than putting these two groups of people together in a environment where both will reasonably feel harassed, employers should have clear rules about facilities that are single-sex, and also, where possible, provide a unisex alternative for anyone who needs it, including people who feel that they have “transitioned away from their sex” and therefore do not wish to use single-sex facilities shared with members of their own sex. The EHRC last year provided guidance on single-sex services which encouraged clear rules and policies.

It should be made clear to people who have the protected characteristic of “gender reassignment” that having this characteristic does not mean it is reasonable for them to expect others to believe or pretend to believe they have changed sex, or for them to be allowed to break (or expect to be an exception to) rules that aim to protect the dignity and privacy of others. 

If a person breaks a clear rule against entering a space provided for the opposite sex, it is not reasonable for them to feel offended when this is pointed out. 

No. It would not be lawful for schools to have a policy that forbids, punishes or denigrates pupils who use clear words about the sex of other people (such as pronouns, but also boy/girl, male/female and so on), nor to require pupils to refer to some classmates as if they were the opposite sex.

• To do so constrains the freedom of speech of pupils in a way that is unjustified and discriminates against them on the basis of belief. 
• It is inconsistent with schools’ safeguarding duty of care , and with their record-keeping responsibilities, for staff to misrepresent the sex of pupils in their records or in introducing them to their peers. 
• In order to explain and enforce sex-based rules designed to keep children safe (such as who is allowed in which showers, toilets, dormitories or sports teams), schools must be able to use clear and unequivocal language. 
• It is not reasonable to expect that a child at school, or transferring between schools, can avoid being “outed” as the sex that they are . 

We do not think that any policy which tells teachers or pupils to lie about the sex of pupils, constrains them from using clear sex-based language or treats them detrimentally if they do would pass the proportionality test. It is an unreasonable constraint on speech that is neither required nor justified in order to avoid discrimination on the basis of gender reassignment. 

Schools form part of a system that is regulated at a national level. In England that system is the responsibility of the Secretary of State for Education. It is the responsibility of the Secretary of State to make this legal situation clear across the English school system by issuing the long-awaited DfE guidance. 

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A decision to undertake gender reassignment is made when an individual feels that his or her gender at birth does not match their gender identity. This is called ‘gender dysphoria’ and is a recognised medical condition.

Gender reassignment refers to individuals, whether staff, who either:

• Have undergone, intend to undergo or are currently undergoing gender reassignment (medical and surgical treatment to alter the body).
• Do not intend to undergo medical treatment but wish to live permanently in a different gender from their gender at birth.

‘Transition’ refers to the process and/or the period of time during which gender reassignment occurs (with or without medical intervention).

Not all people who undertake gender reassignment decide to undergo medical or surgical treatment to alter the body. However, some do and this process may take several years. Additionally, there is a process by which a person can obtain a Gender Recognition Certificate , which changes their legal gender.

People who have undertaken gender reassignment are sometimes referred to as Transgender or Trans (see glossary ).

Transgender and sexual orientation

It should be noted that sexual orientation and transgender are not inter-related. It is incorrect to assume that someone who undertakes gender reassignment is lesbian or gay or that his or her sexual orientation will change after gender reassignment. However, historically the campaigns advocating equality for both transgender and lesbian, gay and bisexual communities have often been associated with each other. As a result, the University's staff and student support networks have established diversity networks that include both Sexual Orientation and Transgender groups.

• 17 Apr Gender Equality Focus Group - Online Session
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gender reassignment

Quick reference.

A physiological and ultimately surgical procedure, under medical supervision, for the purpose of changing a person's sexual characteristics. The process is undertaken by transsexual persons. A transsexual is a person who firmly believes that he or she belongs to the sex opposite to the sex (or gender) to which he or she was assigned by the anatomical structure of his or her body at birth, a condition known as gender dysphoria. It is important to distinguish a transsexual person from a transvestite, who merely wishes to dress in clothes of the opposite sex. Previously, under English law transsexual persons who had undergone gender reassignment were not recognized in their acquired gender, and although able to obtain some official documents in their new name and gender, they could not obtain a new birth certificate or marry in their acquired gender. Under the Gender Recognition Act 2004, a transsexual person may apply to the Gender Recognition Panel for the issue of a full Gender Recognition Certificate. Before issuing the certificate the Panel must be satisfied that the applicant has, or has had, gender dysphoria, has lived in his or her acquired gender for the past two years, and intends to continue to live in that gender until death. The certificate entitles the applicant to be legally recognized in his or her acquired gender, to a new birth certificate, and to marry in that gender. Transsexual persons who have not acquired a Gender Recognition Certificate will not be entitled to have their birth certificates amended and will still only be able to marry in the sex registered at birth. Important cases in this area include Corbett v Corbett [1971] P 83 (HL), Goodwin v UK (App no 28957/95) (2002) 35 EHRR 18, and Bellinger v Bellinger [2003] UKHL 21, [2003] 2 AC 467.

Initially discrimination in the workplace with respect to a person's sexual orientation or transsexualism was outside the ambit of the Sex Discrimination Act 1975 (see sex discrimination). The definition of sex within that Act referred to discrimination on grounds of biological gender and hence covered discrimination only between men and women. As a result of a series of cases before both the European Court of Justice and the European Court of Human Rights, the UK Sex Discrimination Act now includes transsexualism within its definition. As gender reassignment is an ongoing process, regulations have been issued clarifying the protections to be given at the workplace to a transsexual undergoing this process. The Sex Discrimination (Gender Reassignment) Regulations 1999 bring UK law into line with the decision of the European Court of Justice in Case C-13/94 P v S and Cornwall CC [1996] IRLR 347, in which discrimination on grounds of gender reassignment was ruled to be contrary to European Community law.

The Regulations provide protection against discrimination by employers at all stages of the reassignment process, starting when an individual indicates an intention to begin reassignment. The Regulations also cover recruitment procedures, vocational training, and discrimination with respect to pay (see equal pay). The Sex Discrimination Act as amended by the Regulations outlaws direct discrimination and provides for employees who are absent from work to undergo treatment to be treated no less favourably than they would be if the absence was due to sickness or personal injury. The protection is extended to postoperative treatment on a transsexual's return to work. Transsexuals are also protected from harassment. There is a defence to a complaint of less favourable treatment if being a man, or a woman, is a genuine occupational requirement for the employment in question. In addition, there are further supplementary exceptions, some of which apply only temporarily while the process of reassignment is continuing. One exception is where the job is likely to involve the holder of the job being called on to perform intimate body searches pursuant to statutory powers (e.g. a police officer). In that case, however, the employer must take into account whether there are already enough employees who are capable of carrying out those duties whom it would be reasonable to employ on those duties. In no case will less favourable treatment be justified under the exceptions where the individual concerned has acquired a Gender Recognition Certificate under the Gender Recognition Act 2004. This allows for legal recognition of the acquired sex, and the person must be treated as being of that sex for all purposes (Goodwin v UK (App no 28957/95) (2002) 35 EHHR 447; Case C-117/01 KB v National Health Service Pensions Agency [2004] IRLR 240 (ECJ).

From:   gender reassignment   in  A Dictionary of Law »

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

• Decreased antidepressant use
• Decreased anxiety, depression, and suicidal ideation
• Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

• Both a man and a woman
• Neither a man nor a woman
• An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

• Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
• Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
• Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

• Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
• Hysterectomy (uterus removal)
• Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
• Oophorectomy (ovary removal)
• Phalloplasty (surgery to create a penis)
• Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

• Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
• Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

• Constructing a glans (head) to look more like a penis
• Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
• Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

• Breast augmentation
• Facial feminization surgery
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
• Vaginoplasty
• Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

• Acute kidney injury
• Blood transfusion
• Deep vein thrombosis, which is blood clot formation
• Pulmonary embolism, blood vessel blockage for vessels going to the lung
• Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
• Surgical site infection
• Urethral stricture or stenosis, which is when the urethra narrows
• Urinary tract infection (UTI)
• Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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gender reassignment surgery

Definition of gender reassignment surgery

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender through surgery, rather than using surgery to align their outward appearance with their gender identity. Gender confirmation surgery and gender-affirming surgery are the preferred terms in the medical and LGBTQ+ communities, and surgery is seen as one of many possible ways to affirm one's gender identity, rather than as an essential part of transitioning (see transition entry 2 sense 2 )

Examples of gender reassignment surgery in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'gender reassignment surgery.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

1969, in the meaning defined above

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gender reassignment

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“Gender reassignment surgery.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment%20surgery. Accessed 2 Apr. 2024.

Medical Definition

Medical definition of gender reassignment surgery.

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender through surgery, rather than using surgery to align their outward appearance with their gender identity. Gender confirmation surgery and gender-affirming surgery are the preferred terms in the medical and LGBTQ+ communities, and surgery is seen as one of many possible ways to affirm one's gender identity, rather than as an essential part of transitioning (see transition ).

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Definition of 'gender reassignment'

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Definition of gender reassignment noun from the Oxford Advanced American Dictionary

gender reassignment

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Transgender rights advocates rally Jan. 31, 2024, at the Kansas Capitol in Topeka. In 2023, the state enacted a measure that says there are two sexes, male and female, based on a person’s “biological reproductive system" at birth. (AP)

If Your Time is short

This year, 17 state legislatures sought to narrowly define “sex” or “gender” in state law as based solely on biological characteristics. In Utah, one became law.

Although they’re sometimes used synonymously, “sex” and “gender” have different meanings to medical professionals. Sex traditionally refers to one’s biological characteristics, whereas gender is how a person identifies. 

Laws redefining sex in state law could require driver’s licenses and identifying documents to display a person’s sex assigned at birth, a policy that transgender advocates say would lead to discrimination. 

After decades of creating laws that assumed "sex" and "gender" were synonymous, lawmakers across the country are taking another look at how states define those terms.

Scientific and legal interpretations of these words have evolved considerably in the past century. Today , medical experts understand biological sex assigned at birth as more complex and consider it distinct from gender identity.

Until the mid-20th century, Americans' understanding of "sex" was largely biological and binary. "For a substantial time period, law in the United States defined identity categories, such as race and sex, in biological terms," said Darren Hutchinson, an law professor at Emory University law professor.

In the 1950s and ’60s, psychological research emerged that differentiated biological sex from "gender." Researchers coined terms such as "gender roles" as they studied people born with reproductive or sexual anatomy that didn’t fit the typical definitions of male or female and observed how children sometimes developed identity distinct from their biological sex. By the early 1960s, the term "gender identity" began appearing in academic literature. By 1980, "gender identity disorder of childhood" was included in the Diagnostic and Statistical Manual of Mental Disorders’ third edition. This inclusion signaled that the concept of gender identity "was part of the accepted nomenclature being used," said Dr. Jack Drescher, a clinical professor of psychiatry at Columbia University. 

Before the 1970s, the word " gender " was rarely used in American English, according to research by Stefan Th. Gries, a linguistics professor at the University of California, Santa Barbara. He said evidence suggests it was used mostly when discussing grammar to describe the "gender" of a noun in Spanish, for example. 

Edward Schiappa, a professor of communication and rhetoric at the Massachusetts Institute of Technology, observed in his book "The Transgender Exigency" that the rising use of "gender" in English coincided with the term’s introduction into psychological literature and its adoption by the feminist movement. Feminists saw the term as useful for describing the cultural aspects of being a "woman" as different from the biological aspects, he said.

Supreme Court Justice Ruth Bader Ginsberg , who argued sex discrimination cases before the court in the 1970s, said that she intentionally used the term " gender discrimination " because it lacked the salacious overtones "sex" has. After the 1980s, gender’s term usage rose rapidly, moving beyond academic and activist circles. In common American English, "sex" and "gender" began to be used more interchangeably, including in state law — sometimes even in the same section of the law. In Florida’s chapter on driver’s licenses, for example, the section on new license applications uses "gender," but the section on replacement licenses uses "sex."

Today , medical experts and most major medical organizations agree that sex and gender are different. 

Sex is a biological category determined by physical features such as genes, hormones and genitalia. People are male, female or sometimes have reproductive or sexual anatomy that doesn’t fit the typical definitions of male or female, often called intersex.

Gender is different , experts say. Gender identity refers to someone’s internal sense of being a man, woman, or a nonbinary gender . For cisgender people, their sex and gender are the same, while transgender people may experience a mismatch between the two — their gender may not correspond to the sex they were assigned at birth.

Our legal understanding of "sex discrimination" has also evolved.

In 2020, the Supreme Court decided Bostock v. Clayton County , a series of cases in which employers were accused of firing employees for being gay or transgender. The court held that this was a form of "sex discrimination" prohibited under Title VII of the Civil Rights Act of 1964. 

Whether the court will extend this interpretation to other areas of federal law is unclear, legal experts told us. 

Opponents reject the idea that the bills relate to women’s rights and claim the bills are an attempt to "erase" legal recognition of transgender people. In 2023, four states passed laws defining sex , and two other states did so via executive order . The Kansas Legislature, for example, passed the " Women’s Bill of Rights " overriding Democratic Gov. Laura Kelly’s veto . The law says that "pursuant to any state law or rules and regulations … An individual's ‘sex’ means such individual's biological sex, either male or female, at birth." 

The law defines male and female as based on whether a person’s reproductive system "is developed to produce ova," or "is developed to fertilize the ova of a female."

Because of the bill, transgender Kansans may no longer amend the sex listed on their birth certificates or update their driver's licenses to be different from their sex assigned at birth, although courts are reviewing this policy .

The Kansas law also states that "distinctions between the sexes with respect to athletics, prisons or other detention facilities, domestic violence shelters, rape crisis centers, locker rooms, restrooms and other areas where biology, safety or privacy are implicated" are related to "important governmental objectives" a condition required under the equal protection clause of the U.S. Constitution’s 14th Amendment.

Rose Saxe, lawyer and deputy project director of the LGBTQ and HIV project at the American Civil Liberties Union, said the Kansas law does not explicitly require those spaces to be segregated by "sex" as the bill defines, but tries to justify policies that would do so.

This year, 17 more states considered bills that would narrowly define "sex" and/or "gender" in state law according to the ACLU’s anti-LGBTQ legislation tracker . One, Utah , signed a definition into law, and 10 other states are advancing 15 bills combined. In the remaining six states, the bills were carried over to next year or defeated.

Other bills, such as Idaho’s H.B. 421 , don’t replace the word "gender" but declare it synonymous to "sex."  Gender, when used in state law, "shall be considered a synonym for ‘sex’ and shall not be considered a synonym for gender identity, an internal sense of gender, experienced gender, gender expression, or gender role," reads the text of the bill, which passed the Idaho House 54-14 on Feb. 7 . 

Saxe said the bills could have a cascading effect on other laws. Two bills in Florida , neither of which passed, would have explicitly required driver’s licenses to reflect sex assigned at birth. Advocates, including Saxe, worry that other sex-defining bills would have a similar consequence . Transgender rights advocates say access to identification that matches an individual’s identity and presentation is important. "If you can’t update the gender marker on your ID, you are essentially outed as transgender at every turn," said Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality to PolitiFact for a previous story on drivers licenses in Florida. This can happen during interactions with potential landlords, employers, cashiers, bartenders and restaurant servers.

Kentucky and Georgia are following Kansas’s lead and considering their own " Women’s Bill of Rights " based on model legislation created by the conservative advocacy group, Independent Women’s Voice , and the Women’s Liberation Front , a feminist group opposing what it terms " gender ideology ." There are variations. The bill in Georgia , for example, would remove "gender identity" and "sexual orientation" from the state's definition of a hate crime. 

"Even in the states that have passed these bills," said Paisley Currah, a political science professor at the City University of New York, "there's still going to be these contradictions," because a person’s driver's license might not match the gender on their passport, for example.

"Unless you're a prisoner or immigrant or you are in the Army, the government actually doesn't get to look at your body," said Currah, who wrote a book on how government agencies address "sex" categories. "It's always some doctor that signs a letter … and so there's always a document between your body and the state." 

How these sex-defining laws would affect state agencies remains to be seen. And the laws may face court challenges, likely on the grounds that they violate the Equal Protection Clause or right to privacy, Saxe said.

Our Sources

Interview with Paisley Currah, political science professor at the City University of New York, March 20, 2024

Interview with Dr. Jack Drescher, clinical professor of psychiatry at Columbia University, March 19, 2024

Interview with Rose Saxe, Deputy Director for the American Civil Liberties Union’s LGBTQ & HIV Project, March 20, 2024

Email interview with Darren Lenard Hutchinson, law professor at Emory University School of Law, March 20, 2024

Interview with Stefan Th. Gries, linguistics professor at the University of California, Santa Barbara, March 20, 2024

Email interview with Edward Schiappa, Professor of Communication and Rhetoric at the Massachusetts Institute of Technology, March 19, 2024

PolitiFact, " ‘Gender dysphoria’: What it is, what it isn’t and how history has changed its view ," May 22, 2023

Movement Advancement Project, " Defining Sex To Allow Discrimination ," accessed March 21, 2024

PolitiFact, " What Florida’s driver’s license policy change means for transgender people ," Feb. 12, 2024

The Supreme Court of the United States, " Brief for Amici Curiae Corpus-Linguistics " 2019

Taylor & Francis, " The Transgender Exigency | Defining Sex and Gender in the 21st Century ," 2021

The University of Chicago, " How the "Notorious R.B.G." Used Persuasion to Advance Equality ," Dec. 14, 2020

Washington and Lee University Library, " Arguments before the Supreme Court - Ruth Bader Ginsburg: A Reading List ," accessed March 21, 2024

NPR, " Pathmarking the way: Ruth Bader Ginsburg's lifelong fight for gender equality ," Sept. 24, 2020

Los Angeles Times, " Ginsburg Explains Origin of Sex, Gender, " Nov. 21, 1993

Google Books Ngram Viewer, " Gender ," accessed March 20, 2024

Florida Statutes, " Chapter 322 ," accessed March 20, 2024

Florida Statutes, " 322.08 Application for license; requirements for license and identification card forms ,"  accessed March 20, 2024

Florida Statutes, " 322.17 Replacement licenses and permits ," accessed March 20, 2024

American Medical Association, " AMA announced policies adopted on final day of Special Meeting ," June 16, 2021

American Academy of Pediatrics, " Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents ,"  October 2018

American Psychological Association, " sex ," November 15, 2023

American Psychiatric Association, " Definitions of Gender, Sex, and Sexual Orientation and Pronoun Usage ," November 2017

National Institutes of Health, " Sex, Gender, and Sexuality ," Jan. 17, 2024

NPR, " A Guide to Understanding Gender Identity and Pronouns ," June 2, 2021

NHS, " Gender dysphoria ," May 28, 2020

World Health Organization, " Gender and health ," accessed March 19, 2024

American Psychological Association, " gender identity ," November 15, 2023

Centers of Disease Control and Prevention, " Terminology ," Dec. 23, 2022

Cornell Law School, " Bostock v. Clayton County " accessed March 21, 2024

Human Rights Campaign, " The Equality Act ," accessed March 20, 2024

PolitiFact, " What the Equality Act debate gets wrong about gender, sex ," March 4, 2021

CBS News, " Equality Act 2019: House passes sweeping anti-discrimination bill to expand protections of LGBT people ," May 17, 2019

NPR, " House Passes The Equality Act: Here's What It Would Do ," Feb 24, 2021

Movement Advancement Project, " Nondiscrimination Laws ," accessed March 21, 2024

PolitiFact, " In 22 states, gay couples can be legally booted from restaurants. How often that happens is unclear ," June 16, 2023

ACLU, " Mapping Attacks on LGBTQ Rights in U.S. State Legislatures in 2024 ," March 15, 2024

Iowa Governor, " Governor Reynolds Statement on HSB 649 ," Feb. 1, 2024

Erin in the Morning, " Southern states pushing forward with bills ending legal recognition for trans people ," March 18, 2024

NBC News, " By defining sex, some states are denying transgender people legal recognition ," Feb. 27, 2024

NPR, " These states are narrowly defining who is 'female' and 'male' in law ," May 3, 2023

State of Oklahoma, " Executive Order ," Aug. 1, 2023

State of Nebraska, " Executive Order No. 23-16, Establishing a Women's Bill of Rights ," Aug. 30, 2023

Kansas Legislature, " SB 180 ," accessed March 21, 2024

Kansas Legislature, " SB 180 text ,"  accessed March 21, 2024

The Washington Post, " Kansas lawmakers override governor veto to pass anti-trans bathroom bill ," April 27, 2023

Politico, " What’s a woman? Check Kansas law ," April 28, 2023

PBS NewsHour, " Kansas to no longer change transgender people’s birth certificates to reflect gender identities ," Sept. 15, 2023

Kansas Attorney General, " AG Kris Kobach issues formal opinion on Women's Bill of Rights ," June 26, 2023

The Kansas City Star, " Trans Kansans cannot change gender on driver's license while suit continues, judge rules ," March 11, 2024

ACLU, " Kansas v. Harper ," March 21, 2024

Justia, " Equal Protection Supreme Court Cases ," accessed March 21, 2024

Utah Legislature, " Enrolled Copy HB 257 ," accessed March 21, 2024

Arizona Legislature, " SB1628 ," accessed March 21, 2024

KJZZ, " Arizona Senate passes bill spelling out legal definition of 'male' and 'female' " Feb. 23, 2024

LegiScan, " AZ SB1628 ," accessed March 21, 2024

Idaho Legislature, " HB 421 ," accessed March 21, 2024

KTVB, " Idaho House approves gender definitions bill that states there are 'only two sexes' ," Feb. 7, 2024

LegiScan, " Roll Call: ID H0421 ," accessed March 21, 2024

PolitiFact, " What Florida’s driver’s license policy change means for transgender people ," Feb 12. 2024

The Florida Senate, " House Bill 1233 (2024) ," accessed March 21, 2024

The Florida Senate, " House Bill 1639 (2024) ," accessed March 21, 2024 

PBS NewsHour, " Some states seek to deny transgender and nonbinary people’s rights by legally defining sex ," Feb. 27, 2024

The 19th, " More states are pushing to stop legally recognizing trans people in public life ," Jan 24, 2024

The Associated Press, " States' push to define sex decried as erasing trans people ," Feb,. 15, 2023

Kentucky Legislature, " AN ACT relating to sex-based classifications ," accessed March 21, 2024

Georgia General Assembly, " H.B. 1128 ,"  accessed March 21, 2024 

ABC News, "‘ Women's Bill of Rights’ policies could impact daily lives of transgender community ," Feb 13, 2024

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Independent Women’s Voice, " About Us ,"  accessed March 21, 2024

Women’s Liberation Front, " Our Work ," accessed March 21, 2024

NYU Press, " Sex Is as Sex Does ," May 2022 Michigan Law Review, " The Meaning of Sex: Dynamic Words, Novel Applications, and Original Public Meaning ," 2021

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What are ‘sex’ and ‘gender’? How these terms have changed and why states now want to define them

Although they’re sometimes used synonymously, ‘sex’ and ‘gender’ have different meanings to medical professionals..

After decades of creating laws that assumed “sex” and “gender” were synonymous, lawmakers across the country are taking another look at how states define those terms.

Scientific and legal interpretations of these words have evolved considerably in the past century. Today , medical experts understand biological sex assigned at birth as more complex and consider it distinct from gender identity.

In 2020, the Supreme Court also broadened its understanding of sex discrimination in employment to include discrimination based on sexual orientation and gender identity.

Grappling with this cultural, scientific, and legal shift in the meaning of “sex” and “gender,” lawmakers in some states have tried defining the terms narrowly in state law as biological and binary. In 2023, four states passed such laws and, this year, 17 states introduced bills defining “sex.” Some bills in Florida and West Virginia were defeated, but 15 bills are still advancing in states across the country.

This focus on terminology may seem rhetorical, but these legislative changes can restrict access to driver’s licenses and documents that match a person’s gender identity. Transgender rights advocates say that requiring IDs to match the sex a person was assigned at birth can expose transgender Americans to discrimination.

So, how do we understand these terms, and what could these definitions mean for everyday life once codified?

How have the terms ‘sex’ and ‘gender’ evolved?

Until the mid-20th century, Americans’ understanding of “sex” was largely biological and binary.

“For a substantial time period, law in the United States defined identity categories, such as race and sex, in biological terms,” said Darren Hutchinson, an law professor at Emory University law professor.

In the 1950s and ’60s, psychological research emerged that differentiated biological sex from “gender.” Researchers coined terms such as “gender roles” as they studied people born with reproductive or sexual anatomy that didn’t fit the typical definitions of male or female and observed how children sometimes developed identity distinct from their biological sex.

By the early 1960s, the term “gender identity” began appearing in academic literature. By 1980, “gender identity disorder of childhood” was included in the Diagnostic and Statistical Manual of Mental Disorders’ third edition. This inclusion signaled that the concept of gender identity “was part of the accepted nomenclature being used,” said Dr. Jack Drescher, a clinical professor of psychiatry at Columbia University.

Before the 1970s, the word “ gender ” was rarely used in American English, according to research by Stefan Th. Gries, a linguistics professor at the University of California, Santa Barbara. He said evidence suggests it was used mostly when discussing grammar to describe the “gender” of a noun in Spanish, for example.

Edward Schiappa, a professor of communication and rhetoric at the Massachusetts Institute of Technology, observed in his book “The Transgender Exigency” that the rising use of “gender” in English coincided with the term’s introduction into psychological literature and its adoption by the feminist movement. Feminists saw the term as useful for describing the cultural aspects of being a “woman” as different from the biological aspects, he said.

Supreme Court Justice Ruth Bader Ginsberg , who argued sex discrimination cases before the court in the 1970s, said that she intentionally used the term “ gender discrimination ” because it lacked the salacious overtones “sex” has.

After the 1980s, gender’s term usage rose rapidly, moving beyond academic and activist circles. In common American English, “sex” and “gender” began to be used more interchangeably, including in state law — sometimes even in the same section of the law.

In Florida’s chapter on driver’s licenses, for example, the section on new license applications uses “gender,” but the section on replacement licenses uses “sex.”

Modern legal and scientific views of ‘sex’ and ‘gender’

Today , medical experts and most major medical organizations agree that sex and gender are different.

Sex is a biological category determined by physical features such as genes, hormones and genitalia. People are male, female or sometimes have reproductive or sexual anatomy that doesn’t fit the typical definitions of male or female, often called intersex.

Gender is different , experts say. Gender identity refers to someone’s internal sense of being a man, woman, or a nonbinary gender . For cisgender people, their sex and gender are the same, while transgender people may experience a mismatch between the two — their gender may not correspond to the sex they were assigned at birth.

Our legal understanding of “sex discrimination” has also evolved.

In 2020, the Supreme Court decided Bostock v. Clayton County , a series of cases in which employers were accused of firing employees for being gay or transgender. The court held that this was a form of “sex discrimination” prohibited under Title VII of the Civil Rights Act of 1964.

Whether the court will extend this interpretation to other areas of federal law is unclear, legal experts told us.

How have lawmakers responded to this shift?

Recently, lawmakers have tried to codify their understandings of “sex” and “gender” into law.

In some cases, these laws aim to recognize and protect transgender Americans. The Democratic-backed Equality Act , which passed the House, but not the Senate, in 2019 and 2021 , would have federally protected against discrimination based on sex, sexual orientation and gender identity. Some states have passed similar equality legislation , creating a patchwork of anti-discrimination protections for LGBTQ+ people.

But lawmakers in many Republican-led states have proposed narrow definitions of sex and gender that would apply to large sections of state law. “Women and men are not identical; they possess unique biological differences,” Iowa’s Republican governor, Kim Reynolds said in a press release detailing her support for the state’s version of such a bill. She added, “This bill protects women’s spaces and rights afforded to us by Iowa law and the Constitution.”

Opponents reject the idea that the bills relate to women’s rights and claim the bills are an attempt to “erase” legal recognition of transgender people.

In 2023, four states passed laws defining sex , and two other states did so via executive order .

The Kansas Legislature, for example, passed the “ Women’s Bill of Rights ” overriding Democratic Gov. Laura Kelly’s veto . The law says that “pursuant to any state law or rules and regulations … An individual’s ‘sex’ means such individual’s biological sex, either male or female, at birth.”

The law defines male and female as based on whether a person’s reproductive system “is developed to produce ova,” or “is developed to fertilize the ova of a female.”

Because of the bill, transgender Kansans may no longer amend the sex listed on their birth certificates or update their driver’s licenses to be different from their sex assigned at birth, although courts are reviewing this policy .

The Kansas law also states that “distinctions between the sexes with respect to athletics, prisons or other detention facilities, domestic violence shelters, rape crisis centers, locker rooms, restrooms and other areas where biology, safety or privacy are implicated” are related to “important governmental objectives” a condition required under the equal protection clause of the U.S. Constitution’s 14th Amendment.

Rose Saxe, lawyer and deputy project director of the LGBTQ and HIV project at the American Civil Liberties Union, said the Kansas law does not explicitly require those spaces to be segregated by “sex” as the bill defines, but tries to justify policies that would do so.

Current bills defining ‘sex’

This year, 17 more states considered bills that would narrowly define “sex” and/or “gender” in state law according to the ACLU’s anti-LGBTQ legislation tracker . One, Utah , signed a definition into law, and 10 other states are advancing 15 bills combined. In the remaining six states, the bills were carried over to next year or defeated.

Some bills, such as Arizona’s S.B. 1628 change the terms for the entire statute: “This state shall replace the stand-alone term ‘gender’ with ‘sex’ in all laws, rules, publications, orders, actions, programs, policies, and signage,” it reads. The state Senate passed the bill 16-13 on Feb. 22 , along party lines with Republicans in favor.

Other bills, such as Idaho’s H.B. 421 , don’t replace the word “gender” but declare it synonymous to “sex.” Gender, when used in state law, “shall be considered a synonym for ‘sex’ and shall not be considered a synonym for gender identity, an internal sense of gender, experienced gender, gender expression, or gender role,” reads the text of the bill, which passed the Idaho House 54-14 on Feb. 7 .

Saxe said the bills could have a cascading effect on other laws.

Two bills in Florida , neither of which passed, would have explicitly required driver’s licenses to reflect sex assigned at birth. Advocates, including Saxe, worry that other sex-defining bills would have a similar consequence .

Transgender rights advocates say access to identification that matches an individual’s identity and presentation is important. “If you can’t update the gender marker on your ID, you are essentially outed as transgender at every turn,” said Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality to PolitiFact for a previous story on drivers licenses in Florida. This can happen during interactions with potential landlords, employers, cashiers, bartenders and restaurant servers.

Kentucky and Georgia are following Kansas’s lead and considering their own “ Women’s Bill of Rights ” based on model legislation created by the conservative advocacy group, Independent Women’s Voice , and the Women’s Liberation Front , a feminist group opposing what it terms “ gender ideology .”

There are variations. The bill in Georgia , for example, would remove “gender identity” and “sexual orientation” from the state’s definition of a hate crime.

“Even in the states that have passed these bills,” said Paisley Currah, a political science professor at the City University of New York, “there’s still going to be these contradictions,” because a person’s driver’s license might not match the gender on their passport, for example.

“Unless you’re a prisoner or immigrant or you are in the Army, the government actually doesn’t get to look at your body,” said Currah, who wrote a book on how government agencies address “sex” categories. “It’s always some doctor that signs a letter … and so there’s always a document between your body and the state.”

How these sex-defining laws would affect state agencies remains to be seen. And the laws may face court challenges, likely on the grounds that they violate the Equal Protection Clause or right to privacy, Saxe said.

This fact check was originally published by PolitiFact , which is part of the Poynter Institute. See the sources for this fact check here .

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Should Gender Reassignment Surgery be Publicly Funded?

Johann j. go.

Worcester College, University of Oxford, Walton Street, Oxford, Oxfordshire, OX1 2HB UK

Transgender people have among the highest rates of suicide attempts of any group in society, driven strongly by the perception that they do not belong in the sex of their physical body. Gender reassignment surgery (GRS) is a procedure that can change the transgender person’s physical body to accord with their gender identity. The procedure raises important ethical and distributive justice concerns, given the controversy of whether it is a cosmetic or medical procedure and the economic costs associated with performing the procedure. This paper argues that there is a strong case for funding GRS as a matter of clinical necessity and justice. This paper will be divided in four key sections: First, the state of transgender health will be outlined, including the role of GRS and common objections to it. Second, a number of common objections to GRS will be analysed at the outset and shown to be unconvincing. Third, a constructive argument will be advanced, arguing that publicly funded GRS is clinically necessary, cost-effective, and demanded by principles of justice. Fourth, the paper will briefly discuss moralistic biases and why we demand a higher burden of justification for funding GRS compared with other analogous procedures.

Introduction

Healthcare rationing is inevitable. There are finite health resources for an almost infinite number of health needs. Given this reality, this paper analyses whether gender reassignment surgery (GRS) should be funded using our finite health budget and, if so, on what grounds. The issue of publicly funding gender reassignment surgery is fraught with immense difficulty, with complex ethical issues arising from clinical, policy, and economic considerations. The purpose of this paper is to argue that healthcare systems should publicly fund GRS and, where it is already funded, should make it more accessible to patients. The paper serves as additional affirmation for those jurisdictions who already fund GRS, showing that their policies are in line with their ethical and clinical obligations. Transgender persons are those whose physical or assigned sex does not accord with their gender identity (American Psychiatric Association [APA] 2013 ). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), transgender persons generally suffer from gender dysphoria (GD), which is the clinical distress associated with not fitting in their physical sex (APA 2013 ). I will hereinafter use the terms GD and transgender interchangeably. Across virtually all measures of physical and mental health, transgender persons have poorer outcomes than their non-transgender counterparts (Reisner et al. 2016 ). Compared to non-transgender people, transgender persons have higher rates of drug and alcohol abuse, HIV seroprevalence, diabetes, suicide ideation, and suicide attempts (Reisner et al. 2016 ). There is evidence to suggest that as many as 50 per cent of transgender youth experience suicide ideation and as many as 32 per cent have attempted suicide (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D‘Augelli 2011 ). The primary contributor to these poor health outcomes is the transgender person’s strong psychological dissatisfaction with the fact that their physical sex does not correspond to their gender identity (Grossman and D‘Augelli 2011 ).

Gender reassignment surgery is promoted by the world’s leading medical authority on the issue, the World Professional Association for Transgender Health (WPATH), as an effective potential treatment for those whose GD meet specific clinical criteria (WPATH 2011 ). The clinical rationale for GRS is to alleviate the severe psychological angst the transgender person experiences as a result of their gender identity not aligning with their physical sex. Gender reassignment surgery can reduce or eliminate the psychological distress and is strongly associated with the prevention of suicide which might otherwise be attempted (Clements-Nolle et al. 2006 ; Grossman and D’Augelli 2011 ). It is currently offered in the United Kingdom in a limited capacity, with 457 operations performed in the last financial year (NHS, e-mail message to author, May 22, 2018). 1 In New Zealand, a very small number of operations are offered each year subject to very strict conditions, though the waiting list is significant due to a lack of willing surgeons to perform the procedure (Ministry of Health 2012 , 2017 ).

The Problem of GRS Funding

The philosophical literature on GRS is extremely limited, with scant publications focusing on the ethics of publicly funding the procedure. While a range of ethical issues surround the funding of GRS, space constraints necessitate the setting of some parameters for this discussion. First, this paper is concerned only with the funding of gender reassignment surgery in jurisdictions with a state-funded universal healthcare system. It is not concerned with the issue of individual patients having the right to access privately funded GRS. Second, I will assume that those seeking GRS are of legal adult age, competent, and seeking the treatment voluntarily. Third, I will not undertake an analysis of whether or not GD should even be classified as a health issue or not. Arguments in other fields such as sociology have sought to remove GD as a clinical pathology and to instead treat it as a variation of the norm (Ault and Bryzuzy 2009 ). This issue is beyond the scope of this paper, but it should be noted that if GD is removed as a diagnosable clinical condition, it may have implications for transgender persons’ health-based claim to GRS and may therefore affect their ability to draw on the arguments I intend to present. I will instead take the approach of the DSM-5, which classifies GD as a diagnosable mental health condition.

The proposal for publicly funding GRS is, not surprisingly, often met with controversy and strident objections. There are three primary objections to publicly funding GRS: First, GRS may be opposed on the grounds that it is supposedly a cosmetic or enhancement procedure rather than a medical one (NHS 2018 ). Second, those who oppose GRS may advance the claim that it is not cost-effective and that the conditions of scarcity and opportunity costs do not support its funding. Third, a slippery slope argument may be advanced to oppose the public funding of GRS. This argument suggests that if we fund GRS, we will inexorably have to fund other procedures such as elective cosmetic surgery or race-alteration surgery. I demonstrate that these arguments are faulty and unconvincing.

The first objection is what we may call the cosmetic objection. This objection argues that GRS is a cosmetic procedure rather than a clinically necessary one and that we should therefore not fund it. Consider the basic argument structure below:

• P1GRS is a cosmetic procedure.
• P2The state should not publicly fund cosmetic procedures.
• CTherefore, the state should not publicly fund GRS.

The problem with this argument is that it is not clear that Premise 1 or Premise 2 are as defensible as they may initially appear. First, Premise 1 is not altogether convincing, given that GRS is a clinically indicated procedure supported by medical evidence and experts to treat a recognized medical condition (APA 2013 ; WPATH 2011 ). It may involve cosmetic procedures on one level, but it is clearly not solely a cosmetic procedure. The objection therefore sets up a false dichotomy between clinical and cosmetic procedures. Second, even if Premise 1 is granted, it is not clear that Premise 2 can be defended. Some cosmetic procedures may be medically warranted for the attainment of an adequate state of mental and physical health, thus falling under the purview of the healthcare system, and thereby refuting Premise 2. Many public health systems, for example, fully fund breast reconstruction surgery for women who have undergone a mastectomy. This is a cosmetic procedure performed on the grounds that it will improve the patient’s mental well-being. Gender reassignment surgery, even if it involves cosmetic procedures, is done for this same reason. Cosmetic and clinical procedures, therefore, often intersect. Gender reassignment surgery is one such circumstance, given its rationale for promoting the mental and physical health of those with diagnosed GD.

The second objection is based on health resource scarcity and the opportunity costs of funding GRS. Information I obtained from the United Kingdom National Health Service (NHS) via a Freedom of Information Request identifies the average cost of one male-to-female GRS at £10,369 (NHS, e-mail message to author, May 22, 2018). 2 A GRS procedure for a female-to-male, which is far more complex, is an average of £31,780 (NHS, e-mail message to author, May 22, 2018). The majority of GRS performed are for male-to-female assignment, with a total cost to the NHS of £3,525,460 in the financial year of 2016/2017 (NHS, e-mail message to author, May 22, 2018). Using these funds for GRS, it is argued, means unjustifiably depriving other patients of other essential healthcare.

The resource scarcity argument is not convincing. First, GRS can itself be life-saving, and therefore analogous in this way to other essential healthcare services such as intensive care and emergency surgeries that cost more than a single GRS procedure. Without GRS, statistics suggest up to 32 per cent of transgender persons will attempt to commit suicide (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D’Augelli 2011 ; Reisner et al. 2016 ). In purely economic terms, the cost of one death from suicide is identified by some sources at £1.7 million (NHS, 2017a ). It may well transpire, therefore, that a cost–benefit or cost–utility analysis would support funding GRS based on the benefits of saving lives, reducing the economic burden on mental health services, and losing fewer years of productive life to suicide.

Second, as far as medical procedures cost the NHS, this is fairly high, though it is comparable to other procedures which are routinely funded, highlighting the issue of consistency. For example, a lung transplant operation costs the NHS £40,076.32 per patient in the financial year 2016/2017 (NHS 2017b ). A case of complex tuberculosis costs the NHS £21,598.34 (NHS 2017b ). Treatment in an intensive care bed costs £1,932 per night, with a significant portion of patients requiring multiple days of care (NHS 2013 , 2017c ). Gender reassignment surgery fits within these parameters, given its life-saving and economic benefit, and so consistency demands that we either include it as part of the schedule of publicly funded procedures or identify a morally relevant difference. No such morally relevant difference stands up to critical scrutiny, as I shall later demonstrate.

The third objection to GRS is a slippery slope argument, claiming that if we fund GRS it will lead inexorably to the funding of numerous other procedures. For example, we may have to fund surgery for people who demand rhinoplasty. This objection can be responded to, again, through the principles of consistency. I am willing to accept the implications of this objection if, and only if, the rhinoplasty-seeking person experiences the same adverse health effects as the GD-sufferer. If rhinoplasty will prevent a severely anxious and insecure person from committing suicide, then it seems prima facie justified to publicly fund the procedure. However, the standards required to even be a candidate for GRS are very stringent, and similar standards should apply to the hypothetical life-saving rhinoplasty procedure. The patient must have a genuine and identifiable risk of self-harm and have made an autonomous request, there must be no other viable alternative treatments, and rhinoplasty should have been subjected to the two-level funding evaluation process I shall outline.

A related strand is around race appearance alteration surgery, for example, whether funding GRS means the state would also need to fund a dark-skinned person wanting to make her skin fairer on the basis of the mental distress she feels by being dark-skinned. Unlike GRS, race-based surgery may have morally important third-party effects, such as implicitly making others with dark-skin feel devalued or increasing racial stigma. Changing social attitudes is also the preferred approach since the insecurity stems almost purely from racism in society. While transgender people may be stigmatized in society, the primary effect of GD is the internal turmoil experienced independently of society’s discriminatory attitudes. Even if we removed transgender discrimination in society altogether, the GRS-seeking person would still suffer from the internal psychological distress of not belonging in their physical sex (APA 2013 ; WPATH 2011 ). The same does not seem to apply for racism. If we removed racist attitudes from society altogether, it is not clear that the dark-skinned person would continue to experience any distress from their skin colour. 3

The Constructive Argument for GRS

Having shown that the common objections against publicly funding GRS do not succeed, I now turn to a constructive argument in favour of such a policy. My constructive argument is to develop a two-level account with which to justify the public funding of GRS. This approach can also serve as a general framework for evaluating other issues of distributive justice in healthcare and is, in fact, likely already used in various jurisdictions around the world in some form or another. The first level of evaluating whether to fund GRS is to first ascertain whether the condition it intends to treat (i.e. GD) fits the criteria of a health issue and, if so, would the treatment (i.e. GRS) enable the person to improve their health. The second level of evaluation is to consider other morally relevant factors, such as opportunity costs of funding the treatment, third party effects, availability of qualified personnel, existence of alternatives, relative utility, and its impact on justice and health equity. The first-level requirement, namely that GD fits the definition of a health issue and that GRS improves health, is therefore a necessary but not sufficient condition for funding. The second level determines ultimately whether or not to fund GRS, given that the first level evaluation has been satisfied, based upon a series of further ethical considerations.

The First Level of Evaluation

The first stage of the constructive argument is to determine whether or not GRS is a clinically-indicated procedure for a medical condition, based on some definition of health. The definition of health we adopt has profound implications for the two-level approach, since it is the definition that primarily determines whether or not GRS should even be advanced to the second-level for consideration of public funding. At the same time, the definition of health we adopt has implications not only for GRS but for other health conditions more widely. Whatever definition we espouse, we must therefore be prepared to accept its implications and the demands of consistency.

Consider, for example, the World Health Organization’s (WHO) definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948 , 1–2). If a health system is given the duty of promoting health, as indeed is generally the case, then it follows that its responsibilities under a WHO definition will be very broad indeed. On the other hand, Daniel Callahan rejects the WHO concept of health in favour of a purely physical account, where health is merely a state of physical well-being (Callahan 1973 ). One implication of Callahan’s account is that mental health conditions would not fall within the purview of health, and so a health system would have no obligations to provide any mental health services.

Both the WHO and Callahan accounts have implications that few of us would likely be willing to accept. With the WHO account, it may transpire that the health system ought to fund or provide a great number of services on the basis that it would promote a person’s complete physical, mental, and social well-being. For example, it may have to provide lonely rural farmers with sex workers to satisfy their social well-being and buy car fanatics Ferraris to promote complete mental well-being. With Callahan’s account of health, the state has no duty to provide care for those suffering from severe clinical depression, hallucinations, post-traumatic stress disorder, or any other mental illness regardless of its impact. I suspect few of us would be willing to accept the implications of either of these accounts.

Accordingly, I will present a basic definition of health that is pragmatic, likely to be widely accepted, has plausible implications, and is already in use by most healthcare systems. Space constraints will not allow me to defend or develop this account in any detail, but it will be sufficient to support my present argument. I propose that health is a state of physical and mental well-being. To be healthy is to be in an adequate but not necessarily complete nor perfect state of physical and mental health. My basic definition is distinct from Callahan’s account, though not drastically so. The definition does not expand the concept of health to include social and spiritual well-being and can therefore accommodate Callahan’s concerns about the “tyranny of health” where nearly every negative experience ends up being subsumed within the domain of health. The definition also does not give health a utopic or unrealistic goal of complete well-being, unlike the WHO’s definition, which Callahan is rightly critical of. However, my account can capture the problem of mental illness as a domain of health, which accords with most clinicians’ and laypeople’s considered judgements about health. It is also how most health systems and funders today view the nature of health and the role of clinicians.

The basic definition of health I propose is sufficientarian rather than “perfectionist” in nature; it strives to reach a certain threshold rather than some absolute standard. The state has no obligation to promote complete health in all its citizens. A further clarification should also be made. A condition that fits my basic definition of health does not necessarily mean that the state ought therefore to publicly fund the associated treatments. The role of the definition of health is to clarify and delineate which conditions fit within the purview of the healthcare system. There may be other morally relevant considerations, such as opportunity costs, third party effects, availability of qualified personnel, and existence of reliable clinical evidence. However, these considerations should be addressed in the second-level evaluation after understanding the health condition itself. In general, a condition that falls within the purview of the definition of health should at least be given consideration for public funding.

A consistency or derivative argument for the funding of GRS can then be advanced on the basis of this definition of health. First, given the profound effects of GD on mental and physical health, in accordance with our definition, it is a health issue that falls under the purview of the health system. Second, given that we fund a raft of other analogous health conditions on the basis of clinical necessity, for example, depression, anxiety, and other conditions which affect a person’s mental health, consistency demands that we also fund GRS unless we can highlight the presence of morally relevant differences. This argument can, of course, be rebutted by using consistency to argue that we should not fund any of the above treatments for depression or anxiety. However, this would diverge with most reasonable persons’ considered judgement that diagnosable mental health conditions should generally fall within the purview of health. The argument could also be rebutted on the basis of faulty analogy, either on the grounds that GD is not analogous to other mental health conditions or that the treatment for those conditions is not analogous to GRS. This argument, however, is not convincing. The conditions are analogous in that they fit our basic definition of health and are diagnosable conditions with a set of accepted guidelines (APA 2013 ). The treatments are analogous in that they are clinically necessary and are based on an attempt to enable a person to improve towards or reach an adequate state of physical and mental health (WPATH 2011 ).

The claim I am advancing, then, is that what matters for our first level of evaluation is not the specific condition nor the treatment itself, but rather the effect of the condition on the person’s state of physical or mental health and the ability for the treatment to help the person attain an adequate state of physical or mental health. This approach means the first-level evaluation is condition-blind . It does not matter what specific condition it is as long as it fits our definition of health. Gender dysphoria passes the criteria required in the first-level analysis. Gender dysphoria is a recognized and diagnosable condition, which affects a person’s health per our definition. Gender reassignment surgery, as a course of treatment, is supported by the clinical evidence and is effective for restoring a person to the threshold of physical and mental health or at least greatly improving the transgender person’s health (Wierck, Caenege, and Elaut 2011 ; WPATH 2011 ).

The Second Level of Evaluation

Once the first-level evaluation is completed, namely that the condition (GD) be one that fits our definition of health, we turn to the second-level evaluation to analyse other relevant factors regarding public funding. A number of relevant considerations should be taken into account. One important consideration for publicly funding GRS is the wider distributive justice impact as a result of using scarce health resources. These may include considerations of efficiency, relative utility, and opportunity costs. As already pointed out in my rejoinder to the cost-effectiveness objection to funding GRS, the claims of the critics do not stack up empirically. On the face of it, the economic impact of publicly funding GRS seems favourable (NHS 2017a , 2017b ).

Opportunity costs are important considerations in any issue involving health resource allocation, given our finite health budget (Bognar and Hirose 2014 ; Daniels 2008 ). The £10,369 to fund one male-to-female GRS could be used for an alternative need, such as funding a certain number of immunizations or a health promotion programme. There must therefore be strong grounds for funding GRS over another procedure. The case for publicly funding GRS is strong, given its potential to be a life-saving procedure and provide immense benefit to the GD patient (APA 2013 ; WPATH 2011 ).

Identifying and ethically reasoning about opportunity costs is complex, however, as we cannot be certain that cutting funding from one area will mean it going into another area of essential health need. The £10,369 could, for example, be used to install a new car park for the hospital manager or fund a hospital corporate function instead. Opportunity cost is an important consideration to acknowledge as a general principle of distributive justice in healthcare, but it cannot be the sole justification for declining funding unless the treatment is exceedingly expensive such that it would very clearly deprive other patients’ access to an even more important health service. It is not clear that GRS fits this criterion, and so we may not rely solely upon its opportunity costs to deny public funding.

Considerations of justice and health equity are morally relevant in deciding to fund GRS. If a particular procedure has especially high benefits for a marginalized or disadvantaged group, we may have extra grounds for supporting it. This could be defended on a number of different grounds including prioritarian distributive justice, whereby we ought to morally give priority to the worst-off; on utilitarian grounds, whereby the principle of diminishing marginal utility posits that the gain in utility is greater for those who are worse off; or on Rawlsian maximin reasoning (Parfit 1997 ; Rawls 1999 ). Transgender persons remain one of the most discriminated-against people in society, as well as experiencing poorer physical and mental health than their non-transgender counterparts (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D’Augelli 2011 ; Reisner et al. 2016 ). Gender reassignment surgery improves the mental and physical health of a disadvantaged group, and we may therefore have an increased obligation to publicly fund the treatment on prioritarian, Rawlsian, or utilitarian grounds.

Other considerations at the second-level include the availability of qualified medical and support personnel and the availability of viable alternative treatments. Most developed countries have qualified GRS surgeons, often qualified as plastic surgeons. In the event that no qualified medical personnel are available to perform the procedure, the primary obligation becomes recruiting a workforce that is able to perform GRS. It is not an appropriate response to refuse to publicly fund GRS solely on the basis of the state of the workforce, in the same way that if no qualified clinicians are available to treat schizophrenia, the answer is to recruit such personnel rather than using it as a reason to not treat schizophrenics. As for the existence of viable alternative treatments, WPATH does not actually recommend GRS as a first-line course of treatment for those with GD. In fact, there are strict sets of guidelines for clinicians to follow (WPATH 2011). Gender reassignment surgery is therefore the appropriate treatment for certain people, given that there are no viable alternative treatments available for their GD.

One consideration that may worry policymakers is around consumer behaviour and increased demand for GRS services if it becomes fully funded. A number of responses can be offered to address this concern. First, GD is a recognized condition with diagnostic criteria in the DSM and strict treatment protocols outlined in the WPATH document (APA 2013 ; WPATH 2011 ). This fact alone limits the number of those who can make a legitimate claim on the healthcare system to fund their GRS procedure. Second, if the number of people seeking GRS increases as a result of public funding, this will likely be due to more people being able to access a service they needed all along. In such cases, existing clinical need is the driving factor. It is unlikely that people will suddenly “decide” they want to change their gender identity simply because the state now subsidizes GRS. Even if people make decisions on a whim, the criteria in the DSM and WPATH guidelines can respond by declining GRS as an appropriate avenue of treatment. Considerations about inducing demand therefore do not withstand critical scrutiny, and the constructive argument in favour of publicly funding GRS is not affected.

GRS and Moralistic Bias

The constructive argument in favour of public funding GRS, then, can be summarized as follows: First, GD is a recognized clinical condition with diagnosable criteria. It passes the first stage of evaluation, namely that the condition we are treating be one that falls within the purview of the health per our sufficientarian definition (APA 2013 ; WPATH 2011 ). Second, GRS is an effective and evidence-based procedure with clear guidelines, and one that is clinically indicated for the treatment of GD (WPATH 2011 ). Third, considerations of other morally relevant factors do not damage the constructive case to publicly fund GRS. Gender reassignment surgery is cost-effective, and the opportunity costs are worth incurring given its strong potential to be a life-saving procedure (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D’Augelli 2011 ; NHS 2017a ; WPATH 2011). There are strong justice-based considerations grounded in prioritarian, utilitarian, or Rawlsian theory to fund GRS, given that transgender people are one of the most disadvantaged groups in society (Reisner et al. 2016 ). Qualified medical personnel are available to carry out the procedure, and there are no other alternative treatments in the subset of GD patients for whom GRS is clinically indicated (APA 2013 ; WPATH, 2011 ).

The constructive argument I have presented in favour of publicly funding GRS may strike some as surprisingly straightforward. However, the fact that people place such a high burden on having to justify an evidence-based, potentially life-saving medical procedure for a medically recognized condition shows that other biases may be at play. These “moralistic biases” refer to existing views and intuitions people may have about GRS and transgender and gender identity issues in general. If there were a pill that could alleviate a person’s severe psychological distress and prevent them from committing suicide at a one-off cost of £10,369, I suspect the burden of justification to fund it would be significantly less than what is demanded for GRS. The fact that we do not place such a high burden of justification for even more expensive life-saving procedures such as transplants, intensive care, and emergency department treatment shows that there are other intuitions at play in the GRS funding debate.

One of these other intuitions could be an implicit bias against altering the human body in any way (NHS 2018 ). However, altering the human body is often an essential part of medical procedures—appendectomy for the treatment of appendicitis, amputation of a limb with gangrene, or even breast reduction surgery to alleviate weight for those with back problems. These critics would very likely not object to these procedures. The intuition, then, cannot merely be about objecting to altering the body. The biases people have against GRS is probably that they do not see it as a real, medical condition that warrants clinical intervention. Given the large body of medical and scientific evidence about GD and GRS, the burden of proof now rests with those who are attempting to oppose the clinical consensus (APA 2013 ; Ministry of Health 2012 ; NHS 2017a , 2018 ; WPATH, 2011 ). In the absence of a cogent rebuttal of the clinical consensus, we should treat GRS as merely another clinical procedure for a recognized condition.

Another subset of those who oppose the public funding of GRS could be those influenced by conservative or religious views about the rights of transgender people (NHS 2018 ; Schwartz and Lindley 2009 ). In a secular, liberal state, this would arguably be problematic (Raz 1986 ). Decisions about which medical procedures to fund should be informed by clinical evidence, economic analysis, and sound ethical reasoning. If we allow religious views to dictate which clinical procedures to provide, we may find a host of services being opposed, including contraception and sexual health services. Regardless, my constructive argument does not necessarily depend on subscribing to the transgender rights movement. The argument is driven primarily by the notions of clinical necessity, as well as reasoning in an ethically consistent manner given that we fund other analogous life-saving procedures.

Not all opponents of publicly funding GRS are influenced by so-called moralistic biases. The vast majority of people who oppose GRS, I suspect, are simply unaware of the facts surrounding GD and GRS. This is not necessarily through any fault of their own, as the issue is seldom discussed in social or political circles. The lack of awareness of the empirical evidence leads critics of GRS to resort to knee-jerk intuitions, often informed through biases, social attitudes, the media, and prevailing norms. However, once we acknowledge that GD is a recognized clinical condition and that GRS is a cost-effective evidence-based surgical procedure to treat it, it becomes very difficult to continue opposing public funding.

This paper has argued that the state should publicly fund GRS. First, I have argued that initial objections to the state funding GRS do not withstand critical scrutiny. Second, I have gone on to propose a constructive argument, based on the principles of clinical necessity, cost-effectiveness, justice, and ethical consistency. Given that the procedure is analogous to numerous other cost-effective, evidence-based, life-saving procedures we fund routinely, there is a strong argument for publicly funding GRS. Third, I considered a number of further important factors and objections. None of the objections against publicly funding GRS hold, and several considerations lend further support to my constructive case. Once we overcome our initial biases and moralistic intuitions about GD and GRS, and instead treat it as we would any other condition and medical procedure, the positive case for publicly funding GRS becomes very hard to deny.

1 Data from Freedom of Information Request. Received from the NHS via email on May 22, 2018.

2 Information obtained through a Freedom of Information Request. Information received 22 May 2018

3 In our non-ideal real world, I will deliberately leave open the question of whether such race-alteration surgeries should be funded if the dark-skinned person is at very serious risk of suicide, as the lesser of two evils.

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Judith Butler Thinks You’re Overreacting

How did gender become a scary word? The theorist who got us talking about the subject has answers.

“There is a set of strange fantasies about what gender is — how destructive it is, and how frightening it is,” said Judith Butler, whose new book takes on the topic. Credit... Elliott Verdier for The New York Times

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By Jessica Bennett

Jessica Bennett is a contributing editor in Opinion, where she writes about gender, politics and personalities.

• Published March 24, 2024 Updated March 26, 2024

The first thing I did when reading Judith Butler’s new book, “Who’s Afraid of Gender?”, was to look up the word “phantasm,” which appears 41 times in the introduction alone. (It means illusion; the “phantasm of gender,” a threat rooted in fear and fantasy.)

The second thing I did was have a good chuckle about the title, because the answer to the question of who is afraid of gender was … well, I am? Even for someone who’s written on gender and feminism for more than a decade and who once carried the title of this newspaper’s “gender editor,” to talk about gender today can feel so fraught, so politicized, so caught in a war of words that debate, or even conversation, seems impossible.

I am perhaps the intended reader of Butler’s book, in which the notoriously esoteric philosopher turned pop celebrity dismantles how gender has been constructed as a threat throughout the modern world — to national security in Russia; to civilization, according to the Vatican ; to the American traditional family; to protecting children from pedophilia and grooming , according to some conservatives. In a single word, “gender” holds the power to seemingly drive people mad with fear.

Butler’s latest comes more than three decades after their first and most famous book, “Gender Trouble,” brought the idea of “gender as performance” into the mainstream. As it turns out, Butler — who has written 15 books since — never intended to return to the subject, even as a culture war raged. But then the political became personal: Butler was physically attacked in 2017 while speaking in Brazil, and burned in effigy by protesters who shouted, “ Take your ideology to hell .”

This conversation has been condensed and edited for clarity.

Did you ever think you’d see a world in which your ideas would be so widespread — and so fraught?

When I wrote “Gender Trouble,” I was a lecturer. I was teaching five classes, trying to work on this book I thought no one would read. Still, I knew I wasn’t just speaking for myself; there were other people who were strong feminists but also lesbian or gay or trying to figure out gender in ways that weren’t always welcome. But today, the people who are afraid of my ideas are the people who don’t read me. In other words, I don’t think it’s my ideas that they’re afraid of. They’ve come up with something else — a kind of fantasy of what I believe or who I am.

And of course it’s not just my views that are being caricatured, but gender more broadly — gender studies, policies that focus on gender, gender discrimination, gender and health care, anything with “gender” in it is a kind of terrifying prospect, at least for some.

So … who is afraid of gender?

It’s funny, I have a friend, a queer theorist. I told him the book’s name and he said, “Everyone! Everyone’s afraid of gender!”

What’s clear to me is that there is a set of strange fantasies about what gender is — how destructive it is, and how frightening it is — that a number of forces have been circulating: Viktor Orban, Vladimir Putin, Giorgia Meloni, Rishi Sunak, Jair Bolsonaro, Javier Milei, and of course Ron DeSantis, Donald Trump and lots of parents and communities in states like Oklahoma and Texas and Wyoming, who are seeking to pass legislation that bans the teaching of gender or reference to gender in books.

Obviously, those folks are very frightened of gender. They imbue it with power that I actually don’t think it has. But so are feminists who call themselves “gender critical,” or who are trans-exclusionary, or who have taken explicit positions against trans politics.

Can you describe what prompted you to return to this subject?

I was going to Brazil for a conference on the future of democracy. And I was told in advance that there were petitions against me speaking, and that they decided to focus on me because I’m the “papisa,” the female pope, of gender. I’m not quite sure how I got to have that distinction, but apparently I did. I got to the venue early, and I could hear the crowds outside. They’d built a kind of monstrous picture of me with horns, which I took to be overtly antisemitic — with red eyes and kind of a demonic look — with a bikini on. Like, why the bikini?

But in any case, I was burned in effigy. And that freaked me out. And then, when my partner and I were leaving, at the airport, we were attacked: Some woman came at me with a big trolley and she was screaming about pedophilia. I could not understand why.

You thank the young man who threw his body between you and the attacker, taking blows. Was this the first time you’d heard that “ pedophilia ” association?

I had given a talk on Jewish philosophy, and somebody in the back said, “Hands off our children!” I thought, What? I figured out later that the way that the anti-gender ideology movement works is to say: If you break down the taboo against homosexuality, if you allow gay and lesbian marriage, if you allow sex reassignment, then you’ve departed from all the laws of nature that keep the laws of morality intact — which means it’s a Pandora’s box; the whole panoply of perversions will emerge.

As I was preparing to interview you, I received a news alert about the “Don’t Say Gay” settlement in Florida, which says that schools cannot teach about L.G.B.T.Q. topics from kindergarten through the 8th grade, but clarifies that discussing them is allowed . You write that words have become “tacitly figured as recruiters and molesters,” which is behind the effort to remove this type of language from the classroom.

Teaching gender, or critical race theory, or even ethnic studies, is regularly characterized as forms of “indoctrination.” So for instance, that woman who was accusing me of supporting pedophilia, suggests that my work or my teaching would be an effort at “seduction” or “grooming.”

In my experience of teaching, people are arguing with each other all the time. There’s so much conflict. It’s chaotic. There are many things going on — but indoctrination is not one of them.

What about the warping of language on the left?

My version of feminist, queer, trans-affirmative politics is not about policing. I don’t think we should become the police. I’m afraid of the police. But I think a lot of people feel that the world is out of control, and one place where they can exercise some control is language. And it seems like moral discourse comes in then: Call me this. Use this term. We agree to use this language. What I like most about what young people are doing — and it’s not just the young, but everybody’s young now, according to me — is the experimentation. I love the experimentation. Like, let’s come up with new language. Let’s play. Let’s see what language makes us feel better about our lives. But I think we need to have a little more compassion for the adjustment process.

I want to talk for a moment about categories. You have occupied many — butch, queer, woman, nonbinary — yet you’ve also said you’re suspicious of them.

At the time that I wrote “Gender Trouble,” I called for a world in which we might think about genders being proliferated beyond the usual binary of man and woman. What would that look like? What would it be? So when people started talking about being “nonbinary,” I thought, well, I am that. I was trying to occupy that space of being between existing categories.

Do you still believe that gender is “performance?”

After “Gender Trouble” was published, there were some from the trans community who had problems with it. And I saw that my approach, what came to be called a “queer approach”— which was somewhat ironic toward categories — for some people, that’s not OK. They need their categories, they need them to be right, and for them gender is not constructed or performed.

Not everybody wants mobility. And I think I’ve taken that into account now.

But at the same time, for me, performativity is enacting who we are, both our social formation and what we’ve done with that social formation. I mean, my gestures: I didn’t make them up out of thin air — there’s a history of Jewish people who do this. I am inside of something, socially, culturally constructed. At the same time, I find my own way in it. And it’s always been my contention that we’re both formed and we form ourselves, and that’s a living paradox.

How do you define gender today?

Oh, goodness. I have, I suppose, revised my theory of gender — but that’s not the point of this book. I do make the point that “gender identity” is not all of what we mean by gender: It’s one thing that belongs to a cluster of things. Gender is also a framework — a very important framework — in law, in politics, for thinking about how inequality gets instituted in the world.

This is your first book with a nonacademic press. Was that a conscious decision?

Oh, yeah. I wanted to reach people.

It’s funny because many of your ideas do reach people, albeit in internet-era sound bites. I’m thinking about, for instance, of “gender is a drag” T-shirts or “ Judith Butler explained with cats .” It strikes me that a lot of people who claim to have read you have actually just read the Instagram caption of you.

Well, I don’t blame them for not reading that book. It was tough. And some of those sentences are truly unforgivable. Hopefully I didn’t do that in “Who’s Afraid of Gender?”

I feel like I’m more in touch with people who are mobilizing on the ground at the global level than I have been before. And that pleases me.

Jessica Bennett is a contributing editor in the Opinion section of The Times. She teaches journalism at New York University and is the author of “Feminist Fight Club” and “This Is 18.” More about Jessica Bennett

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male-to-female or female-to-male transformation involving surgery and hormone treatment

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How to use gender reassignment in a sentence

Last May, Israel lowered the minimum age for gender reassignment surgery from 21 to 18.