What's Happening on the Continent? 'Sex Change Surgeries' in Germany

Despite relatively strong gatekeeping, gender surgeries have increased exponentially since 2005. And the country is just about to embrace the affirmative model.

Exporting gender medicine into the world

Germany holds a unique place in the history of gender medicine. At the Institut für Sexualwissenschaft (Institute for Sexual Studies) in Berlin, some of the world’s first ‘sex reassignment surgeries’ were performed under the guidance of Magnus Hirschfeld. In 1922, Dora Richter, a trans-identified male, underwent an orchiectomy (removal of the testicles), followed by a penectomy (removal of the penis) and a vaginoplasty in 1931. Around the same time, Lili Elbe, a Danish trans-identified male, underwent similar surgeries, including a uterus transplant. Tragically, Elbe died eight months later due to complications from the transplant.

Long before the Nazis closed the Institute and forced Hirschfeld into exile, another German figure, Harry Benjamin, who had studied at the Berlin Institute and was inspired by Hirschfeld’s work, emigrated to the United States. There, he further developed the field of gender medicine, eventually lending his name to what would later become WPATH (World Professional Association for Transgender Health).

Access to gender medicine in modern Germany

While Germany arguably pioneered medical transition practices, access to gender medicine today remains relatively gatekept by international standards. The affirmative model has not yet become the norm, and patients seeking medical transition must meet certain requirements. These include a formal diagnosis of gender dysphoria, up to one year of prior psychotherapy, and two independent assessments by psychotherapists for public insurance to cover the costs.

Regarding surgical procedures, the current minimum age requirement recommended by the German Association for Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy is 18 years. In principle, this should not merely be a recommendation but a legal requirement. German law explicitly prohibits any medical intervention that results in the sterilization of minors, except for medically necessary interventions to save a patient's life. This means that genital surgeries performed on minors, which inevitably result in sterility, are technically illegal under German law. The ban on sterilization of minors is a lesson drawn from the country’s dark history of widespread forced sterilization of disabled and mentally ill individuals during the Nazi era.¹

Genital Surgeries: A 2,560 % increase since 2005

Data on in-patient surgical procedures in Germany is of very high quality and readily accessible through the country’s federal statistical agency. The relevant data source includes all in-patient surgical procedures covered by public or private insurance, categorized by patient place of residence (state), legal sex, and across 22 age groups from 2005 onward. To keep this article focused, I will refer only to the age groups over the years. Additionally, distinguishing by legal sex can be somewhat misleading because, since 2011, genital surgery has no longer been required for a legal sex change. Therefore, some legally male patients may actually be biologically female, having undergone a gender recognition process beforehand, which changes the sex entry on all legal documents, including the birth certificate. Surgeries paid out-of-pocket are not included.

The data assigns unique identifiers to medical procedures, which is why, in addition to standard medical procedures like appendectomies, it includes ‘sex change operations’ as a distinct category. Importantly, this data only captures transgender-related genital surgeries: for biologically male patients, it records vaginoplasty, and for biologically female patients, phalloplasty.²³

Below (Figure 1), I’ve plotted the incidence rates of the total number of surgeries by age group (age-specific incidence rate: total number of surgeries divided by the population in that specific age group, multiplied by 100,000) on the left-hand side, while the right-hand side shows the raw data (annual number of surgeries). I chose to plot incidence rates because they provide a more accurate representation of how widespread these operations are within each age group. Given that Germany is an aging country, 500 operations in the growing age group of 50-year-olds is less meaningful than 500 operations among the shrinking number of 18-25-year-olds.

Figure 1 (Source: Federal Statistical Office of Germany, own calculations))

The number of sex change operations has shown a sharp increase over the years, coinciding with similar developments in other Western countries. Remarkably, in 2005, there were only 120 such operations in total, whereas by 2023, this number had surged to 3,075. However, focusing solely on the raw numbers misses an important trend: within age groups, these surgeries have become most prevalent among 18- to 25-year-olds. The shift in age demographics, along with the overall explosion in the number of operations, is illustrated in the following graph, which shows the age distribution of these surgeries over multiple years.

Figure 2 (Source: Federal Statistical Office of Germany, own calculations)

In 2005, ‘sex change’ operations were rare, and when performed, patients were mostly in their thirties and forties. While the prevalence has increased across all age groups, nothing compares to the explosion in the 18-25 age category. From just 8 operations in 2005 to over 985 in 2023, this represents a staggering percentage increase of 12 312%. It's important to note that these numbers reflect the number of surgeries, not the number of patients. Since multiple surgeries are sometimes required per individual, the actual number of patients undergoing ‘sex change’ operations is likely lower. Still, even with that in mind, the numbers remain astonishing:

• In total: 24 713 ‘sex change’ operations since 2005

• 6 404 happened in the age category of 18-25 year olds

It was hard to find numbers of other countries to compare to, specifically on genital surgeries. More estimates exist on ‘gender-affirming’ mastectomies and genital surgeries for minors, not a lot for the overall population (see the ‘Do No Harm Database’ and estimates by Leor Sapir⁴). A paper by Wright et al. estimates that in the US 16 872 ‘sex change’ operations took place between 2016 and 2020⁵. In Germany, 9 327 such interventions took place and given that there are roughly 4 times more Americans than Germans, surgical interventions are less restricted than they seem in the first place. Because the authors of the US study make clear that their estimates are likely an undercount, this comparison should be treated with a grain of salt.

The case of minors

According to medical recommendations and the sterilization ban in German law, these medical procedures should not be performed on minors. As the data below shows, they actually are.

Figure 3 (Source: Federal Statistical Office of Germany, own calculations))

While the absolute numbers remain low, their explosive growth suggests that more are yet to come. After submitting an information request to the German Department of Justice (which I personally made), they confirmed that such operations are technically against the law. Yet, in another example of trans exceptionalism, these procedures seem to circumvent clear and pervasive legislation. More importantly, they are officially documented in administrative data, and still, policymakers and journalists remain largely oblivious to the phenomenon.

Paediatric gender medicine: On its way to become an European outlier?

Gender medicine in the West is taking roughly two opposite directions. While Democratic states in the U.S. and all of Canada seem to be expanding access, ignoring recent developments such as the WPATH guidelines and the Cass Review, Republican states, as well as the UK and other European nations, are scaling back, particularly regarding pediatric transition.

What’s ahead for Europe’s largest country? It seems that Germany is following the lead of blue America and Canada, rather than aligning with its European counterparts. Its current progressive government has enacted gender self-ID, and medical associations are currently discussing new guidelines for child gender medicine. When it comes to setting medical standards, the procedure in Germany resembles the American approach more than the centralized decision-making seen in countries like the UK or Sweden. Being a federation like the U.S., medical treatment guidelines are set by medical associations, with policymakers typically not interfering much in the process. When evidence guides the process, this might work well. But in cases of institutional capture, it becomes problematic. The new draft for pediatric gender medicine (not yet enacted) heavily cites WPATH’s SOC 8, and two trans lobby organizations (Bundesverband Trans* and Trans-Kinder-Netz, a ‘trans child’ lobby group) were involved as patient advocacy groups.⁶ The coordinator of the guideline is a medical doctor who runs the Center for Transgender Health in Münster, Germany. When discussed whether minors can consent to medical interventions including surgical interventions that inevitably lead to sterility and are technically outlwaed, the drafts’ authors came up with an interesting justification whose interpretation I leave open:

"When it comes to somatic medical measures for the treatment of gender dysphoria, the assessment of a minor's ability to consent must take into account their developmental stage, particularly regarding their perception and reflection of their own gender identity. Cognitively mature minors with persistent gender incongruence or dysphoria can generally be considered to have the necessary judgment to be regarded as capable of consenting to somatic medical treatment measures." (p. 237) (see footnote 6 for the whole draft)

With gender self-ID starting on November 1, 2024, very pro-pediatric transition guidelines expected to be enacted, and a political and media landscape largely oblivious to the topic, Germany seems to be setting itself apart from the rest of Europe, joining the ranks of blue America and re-importing what is previously exported.

1. There are also strong legal guardrails towards sterilization for adults and specifically adults with physical and mental disabilities.

2. Also, it’s important to note that surgeries due to ambiguous genitalia on individuals with difference of sex development are given a distinct code

3. https://www.icd-code.de/ops/code/5-646.html

4. https://www.city-journal.org/article/a-consensus-no-longer

5. Wright, Jason D., et al. "National estimates of gender-affirming surgery in the US." JAMA Network Open 6.8 (2023): e2330348-e2330348.

6. https://img.welt.de/bin/Entwurf-AWMF-Leitlinie-Geschlechtsinkongruenz_bn-250692300.pdf