A price tag on gender medicine - England

Transgender surgeries have no evidence basis and might entrench distress. Still, they cost the NHS an estimated £41 million pounds between 2020 and 2024.

Disclaimer: The data used for this article was kindly shared with me by LGB Alliance. It was obtained via a freedom of information request to NHS England. This article should be part of a series where I document the extent and fiscal cost of gender medicine in Europe.

Transgender surgeries: Not evidence-based and yet paid for by the public

Transgender surgeries mostly come in three forms. For females, it might involve the removal of breasts (mastectomy) and or genital surgery. A ‘female-to-male’ genital surgery necessarily involves the removal of the uterus and using flesh from the forearm or leg to create a phallus-like structure that is then sown to the groin of a woman. For males, a ‘male-to-female’ genital surgery involves the removal of the penis, the creation of a cavity inside the perineum and the construction of a ‘neo-vagina.’ These operations sterilize a patient and come with a huge number of complications. A 2025 systematic review of genital surgery on both sexes found that for ‘MtF’ surgery, 25-75 % of patients suffer from sexual dysfunction and up to 15 % from urinary incontinence. For ‘FtM’ surgery urinary incontinence is suffered by up to 50 %, whereas 54 % suffer from sexual dysfunction.

As a first line of defense, proponents of (adult) gender medicine claim that these interventions improve the mental health of trans-identified individuals and have been sold as medically necessary interventions. At this stage, it is important to remember that there is no evidence basis for any such claim. Evidence of effectiveness would include a significant reduction in the distress of dysphoric patients after surgical intervention compared to dysphoric patients who are otherwise comparable in all respects but did not undergo such an intervention. In such a case, there would be a treatment group (patients who received the intervention) and a control group, and any potential improvement in life satisfaction or objective health criteria could be attributed to the treatment effect had they evolved in a similar manner prior to the intervention. The often-made claim that access to sex-modifying interventions reduces distress is generally based on scientifically extraordinary weak studies.

For instance, a famous study surveying American trans-identified adults who underwent any form of surgery claimed that levels of psychological distress substantially decreased after surgery relative to trans-identified individuals who have not undergone surgery. However, the groups are different on many metrics such as age or socioeconomic status (so, not a suited control group) and, crucially, the authors rely on self-reported measures of distress. But given the framing of ‘gender-affirming care’, a suppression of critical voices and the stigmatization of detransitioners’ voices in the liberal ecosystem, self-reported happiness is a more than questionable outcome measure. . There is no need to add that there is no long term follow-up.

The same holds true for the common mantra of “the regret rate for trans surgeries is lower than for knee surgery" which relies on a meta study across several post-surgery survey studies on trans-identified indivudals having undergone surgical intervention. There are a lot of problems with these studies which then compound in a meta study. First, they often study totally different populations than the population we see today. The vast majority of studies making it into the meta-study are from the 1980s, 1990s and early 2000s. Back then transgender medicine was much more ‘medicalist’ in that any intervention required a lot of preceding psychotherapy and assessment was much more rigorous. This is nothing like the consumer-oriented approach today which effectively says that if you want this procedure you’ll have it (long waiting times are often not due to rigorous assessment but rather supply side issues). Second, measures of regret again are always subjective. And thirdly, gender medicine is not like any other form of medicine and so cross-comparisons aren’t really valid. Traditionally, medicine is the process of removing an illness. Gender medicine, however, rather resembles medical intervention as a means of self-actualization or as Helen Joyce put it: “gender medicine is tooth fairy medicine.“ In any case, objective measures such as unemployment status or substance abuse would be much more credible measures in that regard.

In fact, when researchers followed up the entirety of individuals who underwent full ‘sex-reassignment’ between 1973-2003 in Sweden, things do not look great. They compared them to otherwise similar individuals from the same birth sex found that suicidality, psychiatric illness and deaths by suicide did not decrease substantially. To be fair, this is also not evidence proving that the practice is inherently harmful. The truth is, we simply do not know and given the politicized nature of this research field, we will likely never now.

At this point, adult gender medicine proponents adopt a bodily autonomy approach. It typically reads: “Why do you care?” or “you seem strangely obsessed with people’s genitals?” But if the public pays for these procedures through a national insurance scheme, the public has a right to a little more bang for the buck. Bodily autonomy might justify treating these interventions as cosmetic interventions (paid for individually) but claiming individual autonomy and handing the bill to the taxpayer is a strange argument. And as will we see, the cost to the (English) taxpayer is not small.

The extent of transgender surgeries within NHS England.

To get an idea about the extent of sex trait modifications within the NHS, LGB Alliance put forward an FOI Request to NHS England and received the following data: Annual number of ‘male-to-female’ genital surgeries, ‘female-to-male’ genital surgeries and ‘masculinising chest surgeries’ (mastectomies) from 2020 until July 2024 on the operating hospital level. They kindly shared the data with me.

There are a few important caveats about the data: The number does not necessarily reflect the number of patients undergoing the surgery as some procedures (in particular ‘‘female-to-male’ genital surgery’ involves several surgical steps). That is, a phalloplasty requires the removal of the uterus and ovaries (hysterectomy) prior to the actual operation. According to the NHS, these operations are all part of the ‘female-to-male genital surgery pathway’ and hence the number of ‘female-to-male’ genital surgeries does not necessarily reflect the number of phalloplasties.

Figure 1 shows the number of transgender surgeries by period.

· 2020: 154 mastectomies and 47 ‘MtF’ genital surgeries were performed. This relatively ‘low’ number is probably due to disruptions caused by the COVID-19 pandemic.

· 2021: 1,155 mastectomies and 223 ‘MtF’ genital surgeries carried out in NHS hospitals across England.

· 2022: 924 mastectomies, 378 ‘MtF’ genital surgeries and, for the first time since 2020, 60 ‘FtM’ genital surgeries were carried out.

· 2023: was the most active year in this period with 881 mastectomies, 445 ‘MtF’ genital surgeries and 106 ‘FtM’ genital surgeries performed.

· Between January and July 2024: there were 535 mastectomies, 116 ‘MtF’ genital surgeries and 70 ‘FtM’ genital surgeries performed. Extrapolate the numbers to the whole year of 2024 and we would see 1070 mastectomies, 232 ‘MtF’ genital surgeries and 140 ‘FtM’ genital surgeries making 2024 the year with the most transgender surgeries in this period.

It seems that while pediatric transition has come under more scrutiny, adult sex trait modifications show little signs of abating. Also, it seems that ‘FtM’ genital surgeries are very much on the rise.

The fiscal cost of transgender surgeries

To get an idea about the cost to the English taxpayer, I use different cost estimates for each surgery. According to a paper by Go (2018), who obtains cost estimates directly from the NHS, an average ‘FtM’ genital surgery costs around £31,780 whereas a ‘MtF’ genital surgery typically costs around £10,369. For mastectomies, I rely on direct information by NHS Scotland who put the average cost per ‘chest reconstruction’ patient (mastectomy) at £5,804. Note that this numbers are partly from 2018, so when you account for inflation this might be a lower bound estimate. By multiplying these cost estimates with the number of annual surgeries, I arrive at the following cost estimates (Figure 2).

I document that from 2020 to July 2024, transgender surgeries have cost NHS England an estimated 41 million pounds, with 2023 being the most expensive year so far (13 million pounds). ‘FtM’ genital surgeries begin to make up an increasing share of the overall costs as they are a) increasing in numbers and b) by far the most expensive type of intervention. If the second half of 2024 continues like its first half, it will be likely be the costliest year so far.

Number and cost of transgender surgeries on the hospital level

NHS England also provided LGB Alliance with data on the hospital level. That is, they were given the name of the NHS hospital and the number of each procedure performed in every year. Hospitals that have been named in this report have been commissioned to provide or has provided gender reassignment operations through the NHS Commissioning – Specialised Services. The NHS data provides the number of individuals who were transferred into a surgical provider by the Gender Dysphoria National Referral Support Service (managed by Arden & GEM Commissioning Support Unit) following its establishment in 2020.

Using the cost estimate, you can determine the ‘cash cows’ of transgender surgeries in the NHS. The breakdown of surgeries performed and the involved cost can be found in Figure 3. Parkside Hospital London received the largest amount of funding for surgeries and also performed the biggest amount of surgeries in total (860 mastectomies and 634 ‘MtF’ genital surgeries, £11,565,386) followed by New Victoria Hospital (185 ‘FtM’ genital surgeries, £5,879,000) and Nuffield Brighton (295 mastectomies and 386 ‘MtF’ genital surgeries, £5,714,614). Many hospitals only perform mastectomies while the centers for ‘FtM’ genital surgery are clearly New Victoria and Chelsea & Westminster Hospital in London. The big centers for ‘MtF’ genital surgery are Nuffield Hospital (Brighton), Parkside Hospital, London and St. George’s, London.

Bang for the buck?

Some might argue that relative to a total NHS budget of £188.5 billion in 2023/2024, 13 million annually is a negligible amount (0,006 %). But this misses two important points:

First, this is only the tip of the iceberg as, post surgery, these patients have become lifelong medical patients requiring exogenous hormonal treatment, the operations come with high rates of complications and infections, subsequent surgeries to fix fistulas and other problems, reversal surgeries and a likely failure to cure gender distress leading to continued mental health issues and treatment. And lastly, what does it say about a publicly funded healthcare system which is under severe fiscal pressure when it sets aside millions of pounds for treatments that have no evidence basis and create life-long medical patients. And should a healthcare system rooted in evidence-based treatment enshrine the esoteric concept of aligning the body to an inner feeling?