This January, Alex Petkanas boarded a flight from Anchorage, Alaska, to Seattle. After years of working with his therapist and medical providers, he was finally on his way to get top surgery, a procedure that removes unwanted breast tissue. It’s a key part of gender-affirming care for many transgender and nonbinary people.
For Petkanas, a 30-year-old transmasculine person, having a body that didn’t match his gender identity was severely affecting his mental health. There were no well-known surgeons who do gender-affirming procedures in the Anchorage area, so he decided to make the three-and-a-half-hour flight to Washington. “Top surgery was something I had wanted for a long time, and at a certain point, it kind of felt like I wasn’t really able to move forward with my life without it,” he said.
There is an enduring myth that getting gender-affirming surgery is “too easy”—that people will get swept up in a temporary vision of themselves, and then come to regret changes they made to their bodies. This concern is particularly large when it comes to top surgeries for teens. “Some clinicians have pointed to the rising demand [of top surgery] and the turmoil of adolescent development as reasons for doctors to slow down before offering irreversible procedures,” wrote Azeen Ghorayshi in a recent widely discussed piece for the New York Times.
But the reality is that the process behind getting top surgery can be long and onerous. Surgeons and health insurance plans typically require one or two letters of support from health professionals showing a diagnosis of persistent gender dysphoria—the psychological distress from the mismatch between one’s biological sex and one’s gender identity. Yet finding someone who practices trans health care can be very difficult. Some insurance plans also insist on at least a year of “successful” “real-life experience” in the patient’s desired gender. The surgery can cost more than $10,000, a sum that can take time to save for. And having the means to fund the surgery isn’t enough: Patients also need to find a surgeon who is willing to use their skills specifically for gender-affirming procedures, many of whom are booked out for months.
Altogether, getting top surgery can take years, even for adults. And for trans or nonbinary kids under 18, the road can be even longer.
“The kid not only needs to come in with persistent and well-documented gender dysphoria, but they also have to have the capacity to understand this care,” said Steph DeNormand, the trans health program manager at Fenway Health, an LGBTQ health care organization in Boston. This usually means having even more detailed conversations about the surgery with younger folks than with adults, DeNormand noted.
Conversations around top surgery for both adults and teens follow a set of standards of care laid out by the World Professional Association for Transgender Health, or WPATH. They include confirming the patient and, if necessary, their parents or guardians understand what top surgery entails, making sure the surgery lines up with the patient’s future goals, and assuring that any other significant mental health concerns are reasonably well controlled at the time of the procedure.
“When we are talking to younger folks before pursuing any kind of care, it’s always with an assessment of what is most appropriate for someone at that age, the level of either distress or dysphoria that they are experiencing, and a balance of risks and benefits,” said DeNormand. Two 12-year-old trans kids, for example, may have vastly different care plans because of their social, emotional, and physical development, and their unique gender goals. “So much of gender-affirming care is individualized because everyone’s priorities and needs are different.”
A step like top surgery won’t be right for every trans or nonbinary person, or teen. “I think that the majority of the time when we are seeing someone who is under the age of 18 who is accessing surgery, it is typically in the context of an extreme level of distress,” said DeNormand.
Numerous studies have shown that gender-affirming care, which includes anything from talk therapy to hormone therapy to gender-affirming surgery, improves mental health in trans and nonbinary people. For those who pursue top surgery, it’s not a panacea against mental health distress. But for many people, it is incredibly helpful. A 2021 paper found that trans people who had received one or more gender-affirming surgeries had a 42 percent reduction in the odds of experiencing psychological distress over the past month and a 44 percent reduction in the odds of suicidal thoughts over the past year. While much of this research has been done on adults, a study published in September analyzed 36 patients aged 13 to 24 who had received top surgery and found that they had significantly less dysphoria and more body image satisfaction three months post-surgery.
Yet there’s a narrative that, despite how long it can take to get top surgery, people will regret the procedure—especially if they are young. In addition to patients who were happy with their choice to get top surgery, Ghorayshi’s piece featured two women who received top surgery as young adults and then subsequently detransitioned. And if you keep up with critics of gender-affirming surgery, you’ve likely heard stories of people regretting their surgeries before. It’s true that some people do regret the surgery, but the number might be smaller than you’d think: Only 1 percent of people who have received gender-affirming surgery report regret, according to a 2021 review of just under 8,000 patients of such surgeries. Regret for gender-affirming surgery is drastically lower than the regret rates of people who have had knee replacement surgery, gotten a tattoo, gone to college, or even had a baby.
“I had top surgery 13 years ago. There is not a day that goes by that I don’t think about how it was the best thing I have ever done for my survival. I also had orthopedic knee surgery at 14 and often regret it,” Chase Strangio, deputy director for transgender justice at the American Civil Liberties Union, recently tweeted.
Regardless of how helpful top surgery can be, even trans adults experience incredible barriers when trying to access surgical care. This includes finding a therapist—a process that can be difficult for anyone. But for those seeking top surgery, a therapist who practices gender-affirming care and is willing to write a letter of support may be particularly hard to find.
“I had a therapist tell me, ‘You’re too pretty to be anything but a girl’ and that she would not be giving me a letter of recommendation for top surgery,” Eri, who wished to be referred to by their first name to protect their medical privacy, wrote in a Twitter message. They had to wait three years to get top surgery.
The procedure is also very expensive. However, even in states that require private insurance to include transgender-related health care, getting coverage can be tough. Additionally, trans people are more likely to be uninsured and experience cost-related barriers to health care than their cisgender peers.
T.L. Pavlich could not get their top surgery covered by insurance. “In the end, I had been waiting for 10 years for the surgery, and the idea of having to wait even longer was heartbreaking, so I took out a loan instead of canceling the appointment,” Pavlich wrote via Twitter. The surgery cost just over $8,000.
Silas Fischer had to make a 17-hour drive from Ohio to Texas to get the surgery. “I needed a surgeon within a certain price range because I was paying out-of-pocket. My insurance would not cover top surgery,” Fischer, whose surgery cost around $7,500, wrote in an email.
Finding and scheduling an appointment with a surgeon is also time-consuming—and many of the well-respected ones have long waitlists.
“I wish I knew how long the process was going to take. I really do,” wrote Bo Belotti, who spent months searching for a surgeon who accepted his insurance. “It was heartbreaking being told I couldn’t even get a consultation.” Thankfully, Belotti eventually found a surgeon.
There is also a dearth of information about the boxes patients must check before getting top surgery and where to find good therapists, medical providers, and surgeons.
“I wish there was more information out there. It’s such a long and complicated process and it seems like everywhere does it differently,” Lennon Sherburne wrote in an email. “The trans community really rallies together to put stuff together, but we deserve clear care information and guidance just like cis folks get.”
Trans and nonbinary youth seeking top surgery must contend with these barriers as well, in addition to intense scrutiny from the media and politicians. People expressing concern about the “risks” of kids getting top surgery often don’t have access to all of the key information, DeNormand said. They don’t see the young person talking to therapists, medical providers, and family about their experiences and feelings.
It is, after all, much easier for cis people to get plastic surgery than for trans people to get gender-affirming care. In 2020, there were 15.6 million cosmetic procedures performed in the U.S., according to the American Society of Plastic Surgeons. Breast augmentations were one of the most popular surgeries, with 3,223 of these procedures performed on people aged 13 to 19.
The multibillion-dollar cosmetic surgery industry is built largely on the promise that cis people can improve their self-esteem and become “better” versions of themselves through physical alterations that assist them in meeting a beauty standard. Critics of gender-affirming surgeries may therefore think that adults and kids getting top surgery are also operating under a similar superficial framework.
“The conversation about trans kids right now is fundamentally broken. Because it is led, by and large, by cis people, it focuses on the potential regret children and adolescents might have after transitioning, and ignores the social, physical, emotional, and psychological costs of not transitioning,” Vox staff writer Emily St. James wrote in a recent article. “It ignores the reams of studies that underline the need to support trans kids. It ignores the lived experiences of many trans people, who despair that they were kept from transitioning as youths.”
There are things people can do to make getting top surgery easier for themselves and their loved ones. These include reaching out to LGBTQ helplines or community centers that can offer advice, and talking to people who have gone through the process. Reading your insurance plan’s medical necessity guidelines for gender-affirming services can also show you the criteria needed for getting the procedure covered.
More than anything, patience is key. “You are going to need an almost superhuman amount of patience for this process,” said Riley Black, a science journalist who contributes to Slate and got her gender-affirming surgery this September. “You know what you need, you know who you are.”
All the years of hard work and patience paid off for Petkanas, who has now recovered from his top surgery. After the procedure, he remembers looking down at his new chest for the first time.
“Immediately, it was clear that this was what I wanted,” Petkanas said. “Everyone has the right to feel comfortable in their body.”