The uncertain scalpel
Surgeons doing transgender procedures say they are operating anxiously under the radar
Indemnity risk
Trans surgery is carried out “under the radar” in Australia’s hospitals and surgeons worry they may “get into trouble” with the country’s taxpayer-funded Medicare system, according to a report from the Australian Society of Plastic Surgeons (ASPS).
Surgeons performing procedures such as double mastectomies and hysterectomies for patients who reject their female sex also fear not being covered against litigation by medical indemnity funds, especially in the public sector.
Obtained under Right to Information law, the summary report from an unprecedented 2023 meeting on “gender-affirming surgery”—attended by plastic surgeons, government health officials and trans activists—suggests that trans procedures are sometimes hidden by a false diagnosis.1
This 15-page account of the Australian Gender-affirming Surgery Roundtable, held in Sydney on 2 December 2023, is likely to reflect current practices and concerns.
The ASPS, apparently assisted by the “gender-affirming” medical lobby, has submitted an unresolved application to the federal government seeking universal public funding under Medicare for demand-driven trans surgery in order to normalise and expand these contentious procedures while addressing the compliance and legal risks facing surgeons.
This project suffered a setback in April 2025 when the ASPS application was put on hold by a federal expert agency, the Medical Services Advisory Committee (MSAC), which raised concerns and requested better evidence of safety and efficacy before making its decision.2
Asked about the timing of this ongoing process, a spokesperson for the Department of Health, Disability and Ageing said: “MSAC will reconsider this application when this work [of supplying more information] is completed. As yet there is no anticipated completion date for this work”.
Like that MSAC application, the 2023 Sydney roundtable focused on adults, but there is growing international concern that young adults whose brains are not fully mature until around the age of 25 may make poor decisions about irreversible gender medicalisation, especially if these would-be patients also suffer from mental health disorders or autism.
The roundtable report implies that trans surgery has “clear and established health benefits”, and does not mention studies showing high rates of suicide and psychiatric disorders after these poorly evidenced interventions.3
Surgeons performing trans procedures told the roundtable that the quality of referrals was “variable”, and “five-minute GP referrals are a problem”.4
GCN asked the ASPS if it could point to any robust studies showing clear health benefits for trans surgery and whether it approved of the practice of using false or misleading diagnoses. ASPS said it did not have a spokesperson available.
Attendees at the 2023 Sydney roundtable included the then ASPS president Nicola Dean; Shruti Pandya, LGBTIQ+ health policy officer at the Department of Health in the state of New South Wales; Dr Ashleigh Lin, president of gender medicine lobby the Australian Professional Association for Trans Health; and trans activist Teddy Cook, a former director of another gender medicine lobby, ACON.
The Sydney roundtable, “facilitated” by a senior health official from the state of South Australia, Ruth Fernandez, heard that the transgender rationale for surgery was sometimes concealed.5
“Hysterectomy would be performed under the banner of ‘dysmenorrhea’ [indicating menstrual cramps, rather than gender dysphoria],” the report says.
Orchidectomies, the removal of testicles for males who reject their sex, were said to be “shrouded in secrecy”.
With double mastectomy—known as “top surgery” in trans circles—there was a practice of “not correcting assumptions that the surgery was breast cancer-related”.
“Surgeons are often stressed by not feeling free to discuss the reason for the surgery.”
They were reportedly worried that—
the surgery might be “disapproved” by the hospital hierarchy if it discovered the “real reason” for the procedure;
and “lack of clarity” about the correct billing item numbers under the Medical Benefits Schedule might lead to trouble with Medicare.
“Worries” such as these, the roundtable report says, might make it difficult to convince more surgeons “that gender-affirming surgery is an attractive area of practice”.
Under the heading “Things that are currently working well”, the report says some trans hysterectomy and top surgery is taking place “in a few public hospitals”.
It says phalloplasty—a radical and costly procedure to create a pseudo-penis for females, with high levels of complications often needing revision surgery—is said to be available at “two major centres” in Australia.
The report also turns its attention to possible downsides if trans surgery shifts, as the authors put it, from “under the radar” and “into the light”.
These risks include an end to surgery now available in the public sector, as the report says happened in South Australia with “facial feminisation” for trans-identified males, which depending on the various procedures involved can cost more than $50,000.6
Attendees at the Sydney roundtable were also worried that private health insurers now willing to fund double mastectomy might exclude cover for the same procedure if it were identified openly as “gender-affirming chest surgery”.
And the report says insurers might restrict all trans surgery to the highest level of cover, if these procedures were accurately described.
The cost of trans surgery ranges from $10,000 for a double mastectomy to $80,000 for phalloplasty.
The roundtable report says trans surgery—which the authors represent as “transformative” because it “allows [a patient] to become their authentic self”—is “expensive or even just impossibly unaffordable”.
Trans surgery should be given long-term public funding—“fund it like cancer,” the report says.
Video: US plastic and reconstructive surgeon Dr Patrick Lappert argues that “gender-affirming” surgery is the wrong response to an untreated psychic wound or disorder
Top surgery for refugees
Invoking the political ideology of “intersectionality”, the report stresses the need for trans surgery access for particular vulnerable groups—indigenous, refugees or migrants on temporary visas, and those with “neurodiversity, especially with non-binary folk”.
And patients should be able to get trans surgery without having to satisfy a mental health assessment. Removing this psychiatric “gatekeeping” would “normalise” trans surgery, making it “like any other surgery, e.g. orthopaedic surgery,” the report says.
The document appears oblivious to concerns that gender clinic caseloads show high levels of psychiatric and personality disorders, autism and ADHD, all of which raise questions about the true cause of gender distress and the best treatment response.
The report views mental health assessment more as a barrier than a safeguard.
“Although gender incongruence is no longer classed as a mental disorder, psychiatric services are still sometimes used as a barrier or hurdle for people before they can access services,” the report says.
“Similarly, particular directors of surgery or psychiatry units may veto [trans] surgery from taking place in their hospital or unit.”
The report favours a role for liaison psychiatry “supporting” the surgical team.
The document complains that specialisations such as orthopaedic surgery “yield better remuneration for hospitals”, thereby crowding out trans surgery from the operating theatres of private facilities. Restrictions on elective surgery in public hospitals are also seen as a problem.
The report reveals that the curriculum for training plastic surgeons was being rewritten to incorporate a specific section on trans surgery, and it recommends that trainees in general practice, psychiatry and surgery all be taught about trans surgery.
GCN does not dispute that gender-affirming advocates believe it is beneficial to expand access to trans surgical interventions
The copy of the report obtained by GCN was sent to Queensland’s then Chief Health Officer Dr John Gerrard on 26 February 2024 with a covering letter from ASPS president Dr Nicola Dean. Presumably the report has been disseminated among other Australian health jurisdictions.
The Medical Services Advisory Committee, which advises Australia’s Health Minister Mark Butler on whether or not to add new health services or technologies to the publicly funded Medicare system, noted the red flag of the changed demographics of the trans population, with an increasing number identifying as non-binary; trans surgery has typically been promoted as a binary, male-to-female or female-to-male intervention.
The committee also said the ASPS application lacked evidence on “the natural history of gender incongruence and dysphoria, qualitative data on the nature of distress experienced by individuals before and after surgery, further information on regret/detransition rates [and] longer-term outcomes”.
The plastic surgeons had adopted the trans activist position that access to taxpayer-funded surgery should require no pathology or distress but merely a feeling of “incongruence” between a subjective “gender identity” and the sexed body.
Activists have largely abandoned “gender dysphoria”, a condition involving clinically significant distress and listed in the diagnostic manual of mental disorders known as DSM-5. The preferred term is “gender incongruence”, which requires no distress at all and was moved to the sexual health chapter of the ICD-11 diagnostic system of the World Health Organisation.
Mr Butler’s expert committee highlighted the fact that “there are no formalised and specific diagnostic criteria in the description of gender incongruence in ICD-11, nor diagnostic criteria to define the severity or duration of gender incongruence to classify it as ‘marked and persistent’.”
Recent studies continue to report poor mental health outcomes following trans surgery. In 2020, the Journal of American Psychiatry published an extraordinary correction after an American-Swedish study reported that trans surgery such as mastectomy or genital reconstruction reduced the need for mental health treatment by 8 per cent a year over the ensuing decade.
This 2019 paper received widespread publicity, with co-author John Pachankis of Yale University declaring, “No longer can we say that we lack high-quality evidence of the benefits of providing gender-affirming surgeries to transgender individuals who seek them”.
A year later, the journal published a correction, an editorial and letters from a dozen psychiatrists, clinicians and researchers in four countries identifying multiple flaws in the 2019 paper, with the conclusion that the data showed no improvement in mental health after surgery or hormonal treatment.
A GP, or general practitioner, is a primary care doctor.
Ms Fernandez is listed as the project manager for the South Australian “gender diversity model of care”. That model of care would allow trans surgery for minors via referral to adult services.
It appears to suggest that “gender-questioning” minors who do not suffer the distress of gender dysphoria may nonetheless access medical treatment such as puberty blockers or cross-sex hormones.
The model estimates that each year 57-161 children aged 6-10 would seek “medical therapies”, with potentially 398-1130 children aged 11-15 also requesting medicalisation. The estimate for the number of 18-24-year-olds wanting “surgical gender affirmation” is 108-545.
It is unclear whether this radical model will be implemented.
In a 2022 social media thread, one poster said: “I’ve been excited to learn recently that apparently some public system surgeons in South Australia now consider Facial Feminisation Surgery [FFS] as being reconstructive surgery [and] are billing Medicare fully accordingly, with nothing but an initial consult fee out of pocket, apparently”. Another poster replied: “Medicare billing for FFS could be huge if it takes off”.
Males outside South Australia were also apparently availing themselves of this arrangement whereby they were given facial feminisation surgery as public patients in hospital beds leased from the private sector. This arrangement had been shut down by February 2024, when the report of the Sydney roundtable was circulating. GCN sought confirmation from the South Australian Department of Health but there was no reply.