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What Is Gender Transitioning?

The process of expressing and affirming one's gender identity

• What It Means
• What It Involves

Social Transitioning

Legal transitioning, medical transitioning, where to find support, how to be an ally.

Gender transitioning describes the process of affirming and expressing one's internal sense of gender rather than the gender assigned to them at birth. It is a process through which transgender and gender-nonconforming people align their presentation or sex characteristics with their gender identity .

Gender transitioning, known more commonly today as gender affirmation, not only involves aesthetic appearances but may also involve changes in social roles, legal recognitions, or physical aspects of the body. Gender transitioning is often described as a binary (male or female) but can also be non-binary , meaning a person is neither strictly male nor female.

This article describes what gender transitioning involves as well as the social, legal, and physical aspects of gender affirmation.

Verywell / Theresa Chiechi

What Does It Mean to Transition?

Gender transitioning is the process by which you express your gender externally ( gender expression ) so that it aligns with how view your gender internally (gender identity). The process has no particular timeline and isn't always linear.

Many transgender and gender-nonconforming people prefer the term "gender affirmation" to "gender transitioning"—in part because transitioning is often taken to mean the process of transforming one medically. In fact, a person doesn't need to undergo medical treatment to affirm their identity, and some transgender people avoid hormones or gender-affirming surgery.

Gender transitioning is a holistic process, addressing all aspects of who a person is inwardly and outwardly. It can be broadly categorized into three types:

• Social transitioning : Relating to how you present yourself to the world
• Legal transitioning : Relating to the recognition of your gender through legal means
• Medical transitioning : Relating to treatments that align your body with your gender identity

Certain aspects of gender transitioning may be more important to some people than others (such as changing your name and gender on your birth certificate). It is also possible to reevaluate and revise your gender identity as part of a lifelong continuum rather than as a step-by-step, one-way process.

Exploring Your Gender Identity

Gender transitioning is a process that often starts in response to gender dysphoria . Gender dysphoria describes the persistent sense of unease that occurs when the gender you were assigned at birth does not match how you experience or express your gender internally. Some people have experienced symptoms of gender dysphoria as early as 3 or 4 years of age.

Gender dysphoria can be largely informed by the culture you live in, particularly in cultures where there are strict codes as to what is masculine/male and feminine/female.

The unease can be expressed in children in different ways, including:

• A strong preference for clothes typically worn by the other gender
• A strong aversion to clothes typically worn by their own gender
• A strong preference for cross-gender roles in fantasy play
• A strong preference for the toys, games, or activities typically used by the other gender
• A strong preference for playmates of the other gender
• A strong dislike of one’s sexual anatomy

For many, gender dysphoria fully emerges during puberty when awareness about how their body defines them creates internal distress. Feelings of unease may be amplified when a child is described as "tomboy" or "sissy," or is criticized and attacked for "acting like a girl" or "acting like a boy."

With physical changes during puberty, long-standing feelings that "I don't fit in" may evolve into feelings that "I don't fit into my own body." It is then that children or teens may undergo a process referred to as internal transitioning. This is when you start to change how you see yourself.

Gender transitioning/affirmation is the next step. There is no set course as to how a person aligns their internal sense of gender with their outward expression of gender identity. Gender transitioning is not about "changing" or "recreating" oneself. It's about expressing one's authentic self and asserting who you are socially, legally, and/or medically.

Social transitioning involves how a person publicly expresses their gender to the world at large.

Social transition can take many forms:

• Changing your pronouns
• Using your chosen name
• Coming out to friends, family, and colleagues
• Wearing new clothes
• Cutting or styling your hair differently
• Changing your manner (such as how you sit)
• Changing how you speak or use your voice
• Packing (wearing a penile prosthesis to create a penile bulge)
• Tucking (tucking your penis to conceal a penile budge)
• Binding (strapping your chest to hide your breasts)
• Wearing breast and hip prosthetics to accentuate "feminine" curves

Social affirmation may also include playing certain sports, pursuing different lines of work, or partaking in activities that some might typically see as "male" or "female."

Legal transitioning is about legal recognition. It involves changing legal documents to reflect your chosen name, gender, and pronouns.

This includes governmental and non-government documents such as:

• Bank records
• Medical and dental record
• Driver's license
• Voter's registration card
• Birth certificates
• Social Security ID

The provisions allowing for these changes can vary by state.

Some states will only allow changes if "bottom surgery" (genital reconstruction) is performed, while others will allow you to do so without any form of gender-affirming surgery. Other states have begun to offer an "X" gender option for people who are non-binary.

Medical transitioning most commonly involves hormone therapy to develop some of the desired secondary male or female sex characteristics. It can also involve surgery to change certain physical aspects that hormone therapy alone can't change.

Hormone Therapy

Hormone therapy helps people look physically more like the gender they identify as. They are sometimes used on their own and may also be used before gender-affirming surgery to improve outcomes.

Gender-affirming hormone therapy takes two forms:

• Transgender men can take testosterone to help deepen their voice, increase muscle mass, promote body and facial hair, and enlarge their clitoris.
• Transgender women can take estrogen as well as a testosterone blocker to redistribute body fat, increase breast size, reduce male-pattern baldness, and reduce testicle size.

Gender-Affirming Surgery

Gender affirmation surgery is used to align a person's physical appearance to their gender identity. Many hospitals offer gender-affirming surgery through a department of transgender medicine.

Gender-affirming medical procedures include: 

• Breast augmentation : Increasing breast size with implants
• Chest masculinization : Removing and contouring of breast tissues
• Facial surgery : Including facial feminization surgery
• Tracheal shaving : Used to reduce the Adam's apple
• Phalloplasty : Construction of a penis 
• Scrotoplasty : Construction of a scrotum
• Vaginoplasty : Construction of the vaginal canal
• Vulvoplasty : Construction of the outer female genitals
• Orchiectomy : Removal of the testicles

Barriers to Gender Transitioning

Transgender people are protected from public and private insurance discrimination under federal and state laws, including Medicare and Medicaid.

Even so, Medicaid programs in nine states offer no coverage of gender-affirming medical treatments, and only two (Illinois and Maine) offer the comprehensive standard of care recommended by the World Professional Association for Transgender Health (WPATH).

Medicare also has no consistent policy regarding the approval of gender-affirming surgery. It instead relies on precedents in individual states to direct whether a treatment is approved or not. As such, states in which Medicaid coverage is denied may also be more likely to deny Medicare coverage.

In terms of private insurance, most providers have removed restrictions on gender-affirming care. Although larger insurers (like Aetna and Cigna) usually cover a more comprehensive array of services, in full or in part, many smaller insurers do not (or may only cover things like hormone therapy).

Even if treatments are covered, private insurers will often require psychological evaluations and health screenings that non-transgender people would never be asked to undergo (such as for breast reconstruction).

Another barrier is stigma and discrimination. Studies have shown that no less than 53% of transgender people report being harassed or bullied in public. Others report family or partner disapproval as the main reason why they abandon gender affirmation.

These factors can discourage transgender people from seeking gender-affirming care or embarking on treatments they would otherwise desire.

Gender transitioning can be complex and overwhelming, but there are organizations that can help with everything from insurance coverage to simply having someone to share your feelings with.

Here are some of the leading support organizations:

• Transgender Institute offers individual and group therapy for transgender youths and adults to better cope with stigma, discrimination, family issues, substance abuse problems, and transphobia .
• World Professional Association for Transgender Health offers a list of mental health providers by state who are experienced and trained in gender-affirming care.
• Pride Counseling is a paid mobile app that connects users to licensed therapists specializing in LGBTQI+ counseling.
• National Center for Transgender Equality offers a step-by-step guide to help transgender people obtain insurance coverage for gender-affirming care.
• The Trevor Project offers a 24/7 hotline for transgender youths in crisis or in need of a safe space to talk.
• Gay & Lesbian Alliance Against Defamation (GLAAD ) offers a comprehensive list of resources for transgender adults and youth.
• Transgender Legal Defense and Eductions Fund offers resources to assist with legal affirmation, insurance access, financial assistance, and legal action for transgender people who are unjustly denied gender-affirming care.

If you know someone who is transgender or is considering transitioning, learning how to be supportive is the best way to be an ally. Educate yourself about gender and gender transitioning. Everyone's transition is different, and there is no right or wrong way to do it.

Take the first step by asking the person's pronouns and affirmed name. It’s an act of respect, and everyone deserves to be addressed in the way they choose.

Gender transitioning, more commonly known today as gender affirmation, is the process taken by transgender people to align their internal gender identity with their external gender expression.

Gender transitioning may involve social affirmation (such as dressing differently or coming out to friends and family), legal affirmation (changing your name and gender on legal documents), or medical affirmation (using hormones and/or surgery to change certain physical aspects of your body). Transgender people can pursue some or all of these.

Barriers to gender transitioning include cost, lack of insurance, stigma, discrimination, and lack of family or partner support.

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King WM, Gamerel KE. A scoping review examining social and legal gender affirmation and health among transgender populations . Transgend Health. 2021;6(1):5–22.. doi:10.1089/trgh.2020.0025

Irwig MS, Childs K, Hancock AB. Effects of testosterone on the transgender male voice. Andrology . 2017;5(1):107-112. doi: 10.1111/andr.12278

Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women.   Lancet Diabetes Endocrinol . 2017;5(4):291-300. doi: 10.1016/S2213-8587(16)30319-9

National Center for Transgender Equality. Know Your Rights in Health Care.

Kaiser Family Foundation. Update on Medicaid coverage of gender-affirming health services .

Center of Medicare and Medicaid Services. Gender dysphoria and gender reassignment surgery .

Transgender Legal Defense and Education Fund. Health insurance medical policies .

National Center for Transgender Equality and National Gay and Lesbian Task Force. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey.

Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors leading to “detransition” among transgender and gender diverse people in the United States: a mixed-methods analysis . LGBT Health. May/June 2021;8(4):273–80. doi:10.1089/lgbt.2020.0437

By S. Nicole Lane Lane is a freelance health journalist focusing on sexual health and LGBTQ wellness based in Chicago, Illinois. She began writing about health after living with vaginismus for eight years.

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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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What Is Gender Affirmation Surgery?

Surgery to change the appearance of your body is a common choice for all kinds of people. There are many reasons that people might want to alter their appearance. For transgender or gender nonconforming people, making changes to their bodies is a way of affirming their identity.

A trans person can choose from multiple procedures to make their appearance match their self-identified gender identity. Doctors refer to this as gender "affirmation" surgery.

Trans people might decide to have surgery on their chest, genitals, or face. These surgeries are personal decisions, and each person makes their own choices about what is right for them.

Learn more about gender affirmation surgery and how it helps trans people.

What Does It Mean to Be Transgender or Nonbinary?

Transgender is a word to describe people whose gender identity or gender expression doesn't match the sex they were assigned at birth. Typically, parents and doctors assume a baby's gender based on the appearance of their genitals. But some people grow up and realize that their sense of who they are isn't aligned with how their bodies look. These people are considered transgender.

Trans people may identify as a different gender than what they were assigned at birth. For example, a child assigned male at birth may identify as female. Nonbinary people don't identify as either male or female. They may refer to themselves as "nonbinary" or "genderqueer."

There are many options for trans and nonbinary people to change their appearance so that how they look reflects who they are inside. Many trans people use clothing, hairstyles, or makeup to present a particular look. Some use hormone therapy to refine their secondary sex characteristics. Some people choose surgery that can change their bodies and faces permanently.

Facial Surgery

Facial plastic surgery is popular and accessible for all kinds of people in the U.S. It is not uncommon to have a nose job or a facelift . Cosmetic surgery is great for improving self-esteem and making people feel more like themselves. Trans people can use plastic surgery to adjust the shape of their faces to better reflect their gender identity.

Facial feminization. A person with a masculine face can have surgeries to make their face and neck look more feminine. These can be done in one procedure or through multiple operations. They might ask for:

• Forehead contouring
• Jaw reduction
• Chin surgery
• Hairline advancement
• Cheek augmentation
• Rhinoplasty
• Lip augmentation
• Adam's apple reduction

Facial masculinization. Someone with a feminine face can have surgery to make their face look more masculine. The doctor may do all the procedures at one time or plan multiple surgeries. Doctors usually offer:

• Forehead lengthening
• Jaw reshaping
• Chin contouring
• Adam's apple enhancement

Top Surgery

Breast surgeries are very common in America. The shorthand for breast surgeries is "top surgery." All kinds of people have operations on their breasts , and there are a lot of doctors who can do them. The surgeries that trans people have to change their chests are very similar to typical breast enhancement or breast removal operations.

Transfeminine. When a trans person wants a more feminine bustline, that's called transfeminine top surgery. It involves placing breast implants in a person's chest. It's the same operation that a doctor might do to enlarge someone's breasts or for breast reconstruction .

Transmasculine. Transmasculine top surgery is when a person wants a more masculine chest shape. It is similar to a mastectomy . The doctor removes the breast tissue to flatten the whole chest. The doctor can also contour the skin and reposition the nipples to look more like a typical man's chest.

Bottom Surgery

For people who want to change their genitals, some operations can do that. That is sometimes called bottom surgery. Those are complicated procedures that require doctors with a lot of experience with trans surgeries.

Transmasculine bottom surgery. Some transmasculine people want to remove their uterus and ovaries. They can choose to have a hysterectomy to do that. This reduces the level of female hormones in their bodies and stops their menstrual cycles.

If a person wants to change their external genitals, they can ask for surgery to alter the vaginal opening. A surgeon can also construct a penis for them. There are several techniques for doing this.

Metoidioplasty uses the clitoris and surrounding skin to create a phallus that can become erect and pass urine. A phalloplasty requires grafting skin from another part of the body into the genital region to create a phallus. People can also have surgery to make a scrotum with implants that mimic testicles. ‌

Transfeminine bottom surgery. People who want to reduce the level of male hormones in their bodies may choose to have their testicles removed. This is called an orchiectomy and can be done as an outpatient operation.

Vaginoplasty is an operation to construct a vagina . Doctors use the tissue from the penis and invert it into a person's pelvic area. The follow-up after a vaginoplasty involves using dilators to prevent the new vaginal opening from closing back up.

How Much Does Gender Affirmation Surgery Cost?

Some medical insurance companies will cover some or most parts of your gender-affirming surgery. But many might have certain "exclusions" listed in the plan. They might use language like "services related to sex change" or "sex reassignment surgery." These limitations may vary by state. It's best to reach out to your insurance company by phone or email to confirm the coverage or exclusions.

If your company does cover some costs, they may need a few documents before they approve it.

This can include:

• A gender dysphoria diagnosis in your health records. It's a term used to describe the feeling you have when the sex you're assigned at birth does not match with your gender identity. A doctor can provide a note if it's necessary.
• A letter of support from a mental health professional such as a social worker, psychiatrist , or a therapist.

Gender affirmation surgery can be very expensive. It's best to check with your insurance company to see what type of coverage you have.

If you're planning to pay out-of-pocket, prices may vary depending on the various specialists involved in your case. This can include surgeons, primary care doctors, anesthesiologists, psychiatrists, social workers, and counselors. The procedure costs also vary, and the total bill will include a number of charges, including hospital stay, anesthesia, counseling sessions, medications, and the procedures you elect to have.

Whether you choose facial, top, or bottom or a combination of these procedures, the total bill after your hospital stay can cost anywhere from $5,400 for chin surgery to well over $100,000 for multiple procedures.

Recovery and Mental Health After Gender Affirmation Surgery

Your recovery time may vary. It will depend on the type of surgery you have. But swelling can last anywhere from 2 weeks for facial surgery to up to 4 months or more if you opted for bottom surgery.

Talk to your doctor about when you can get back to your normal day-to-day routine. But in the meantime, make sure to go to your regular follow-up appointments with your doctor. This will help them make sure you're healing well post-surgery.

Most trans and nonbinary people who get gender affirmation surgery report that it improves their overall quality of life. In fact, over 94% of people who opt for surgery say they are satisfied with the results.

Folks who have mental health support before surgery tend to do better, too. One study found that after gender affirmation surgery, a person's need for mental health treatment went down by 8%.

Not all trans and nonbinary people choose to have gender affirmation surgery, or they may only have some of the procedures available. If you are considering surgery, speak with your primary care doctor to discuss what operations might be best for you.

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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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• Gender reassignment discrimination

Published: 22 December 2021

Last updated: 23 February 2023

On this page

What the equality act says about gender reassignment discrimination, different types of gender reassignment discrimination, circumstances when being treated differently due to gender reassignment is lawful, pages in this guide.

• Your rights under the Equality Act 2010
• Age discrimination
• Disability discrimination
• Marriage and civil partnership discrimination
• Pregnancy and maternity discrimination
• Race discrimination
• Religion or belief discrimination
• Sex discrimination
• Sexual orientation discrimination
• Terms used in the Equality Act
• Harassment and victimisation
• Direct and indirect discrimination

What countries does this apply to?

On this page we have used plain English to help explain legal terms. This does not change the meaning of the law.

The Equality Act 2010 uses the term ‘transsexual’ for individuals who have the protected characteristic of gender reassignment. We recognise that some people consider this term outdated, so we have used the term ‘trans’ to refer to a person who has the protected characteristic of gender reassignment. However, we note that some people who identify as trans may not fall within the legal definition.

This page is subject to updates due to the evolving nature of some of the issues highlighted. 

This is when you are treated differently because you are trans in one of the  situations covered by the Equality Act . The treatment could be a one-off action or as a result of a rule or policy. It doesn’t have to be intentional to be unlawful.

There are some circumstances when being treated differently due to being trans is lawful. These are explained below.

The Equality Act 2010 says that you must not be discriminated against because of gender reassignment.

In the Equality Act, gender reassignment means proposing to undergo, undergoing or having undergone a process to reassign your sex.

To be protected from gender reassignment discrimination, you do not need to have undergone any medical treatment or surgery to change from your birth sex to your preferred gender.

You can be at any stage in the transition process, from proposing to reassign your sex, undergoing a process of reassignment, or having completed it. It does not matter whether or not you have applied for or obtained a Gender Recognition Certificate, which is the document that confirms the change of a person's legal sex. 

For example, a person who was born female and decides to spend the rest of their life as a man, and a person who was born male and has been living as a woman for some time and obtained a Gender Recognition Certificate, both have the protected characteristic of gender reassignment. 

There are four types of gender reassignment discrimination.

Direct discrimination

Direct discrimination happens when someone treats you worse than another person in a similar situation because you are trans.

You inform your employer that you intend to spend the rest of your life living as the opposite sex. If your employer alters your role against your wishes to avoid you having contact with clients, this would be direct gender reassignment discrimination.

The Equality Act says that you must not be directly discriminated against because:

• you  have  the protected characteristic of gender reassignment. A wide range of people identify as trans. However, you are not protected under the Equality Act unless you have proposed, started or completed a process to change your sex.
• someone  thinks   you   have  the protected characteristic of gender reassignment. For example, because you occasionally cross-dress or do not conform to gender stereotypes (this is known as discrimination by perception).
• you are  connected   to  a person who has the protected characteristic of gender reassignment, or someone wrongly thought to have this protected characteristic (this is known as discrimination by association).

Absences from work

If you are absent from work because of your gender reassignment, your employer cannot treat you worse than you would be treated if you were absent:

• due to an illness or injury.

Example –  

Your employer cannot pay you less than you would have received if you were off sick.

• due to some other reason - however, in this case it is only discrimination if your employer is acting unreasonably.

If your employer would agree to a request for time off for someone to attend their child’s graduation ceremony, then it may be unreasonable to refuse you time off for part of a gender reassignment process. This would include, for example, time off for counselling.

Indirect discrimination

Indirect discrimination happens when an organisation has a particular policy or way of working that puts people with the protected characteristic of gender reassignment at a disadvantage. Sometimes indirect gender reassignment discrimination can be permitted if the organisation or employer is able to show that there is a good reason for the discrimination. This is known as  objective justification .

An employer has a practice of starting induction sessions for new staff with an ice-breaker designed to introduce everyone in the room to each other. Each worker is required to provide a picture of themselves as a toddler. One worker is a trans woman who does not wish her colleagues to know that she was brought up as a boy, so she does not bring her photo and is criticised by the employer in front of the group for not joining in. The same approach is taken for all new staff, but it puts people with the protected characteristic of gender reassignment at a particular disadvantage.  This would be unlawful indirect discrimination unless the employer could show that the practice was justified.

Harassment is when someone makes you feel humiliated, offended or degraded for reasons related to gender reassignment.

A person who has undergone male-to-female gender reassignment is having a drink in a pub with friends and the landlord keeps calling her ‘sir’ or ‘he’ when serving drinks, despite her complaining about it.

Harassment can never be justified. However, if an organisation or employer can show it did everything it could to prevent people who work for it from harassing you, you will not be able to make a claim for harassment against the organisation, only against the harasser.

Victimisation

Victimisation is when you are treated badly because you have made a complaint of gender reassignment discrimination under the Equality Act. It can also occur if you are supporting someone who has made a complaint of gender reassignment discrimination.

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.

A difference in treatment may sometimes be lawful. This will be the case where the circumstances fall under one of the exceptions in the Equality Act that allow organisations to provide different treatment or services on the basis of gender reassignment.

Examples –    

The organisers of a women’s triathlon event decide to exclude a trans woman with a Gender Recognition Certificate as they think her strength or stamina gives her an unfair advantage. However, the organisers would need to be able to show that this was necessary to make the event fair or safe for everyone.

A service provider provides single-sex services. The Equality Act allows a lawfully established separate or single-sex service provider to prevent, limit or modify people’s access on the basis of gender reassignment in some circumstances. However, limiting or modifying access to, or excluding a trans person from, the separate or single-sex service of the gender in which they present will be unlawful if you cannot show such action is a proportionate means of achieving a legitimate aim. This applies whether or not the person has a Gender Recognition Certificate.

Updated: 23 Feb 2023

• Removed paragraph on language recommendations made by Women and Equalities Committee (WEC) in 2016
• Removed the term ‘transsexual’ as per WEC 2016 recommendations
• Added paragraph explaining use of plain English in the guidance
• Removed a paragraph on intersex people not being explicitly protected from discrimination by the Equality Act

Page updates

22 December 2021

Last updated:

23 February 2023

Advice and support

If you think you might have been treated unfairly and want further advice, you can contact the  Equality Advisory and Support Service (EASS) .

The EASS is an independent advice service, not operated by the Equality and Human Rights Commission.

Phone: 0808 800 0082  

Call the EASS on:

0808 800 0082

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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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Dictionary Entries Near gender reassignment surgery

gender reassignment

gender-specific

Cite this Entry

“Gender reassignment surgery.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment%20surgery. Accessed 8 Jun. 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 entry 2 ).

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• Sexual Health Q&A

What is gender reassignment surgery?

Reviewed by the medical professionals of the ISSM’s Communication Committee

Gender reassignment surgery, sometimes called sex reassignment surgery, is performed to transition individuals with gender dysphoria to their desired gender.

People with gender dysphoria often feel that they were born in the wrong gender. A biological male may identify more as a female and vice versa.

• Surgery is typically the last step in the physical transition process, but it is not a decision to be made lightly.
• Many healthcare providers require patients to be formally diagnosed with gender dysphoria and undergo counseling to determine if they are truly ready to surgically transition.
• Patients usually undergo hormone therapy first. Hormones can suppress the secondary sex characteristics of the biological gender and make them appear more like their desired sex. For instance, women take androgens and start developing facial hair. Men take estrogens and anti-androgens to look more feminine.
• Surgeons may also require that patients live as their desired gender for at least one year. A man might dress as a woman traditionally does in the culture. Many men change their names and refer to themselves with female pronouns. Women transitioning to men would do the reverse.

Surgical transition may include several procedures.

• Males transitioning to females have their testicles and penis removed. The prostate gland may or may not be removed as well. Tissue from the penis is used to construct a vagina and clitoris. Labia – the “lips” surrounding the vagina – can be made from scrotal skin. The urethra (the tube from which urine leaves the body) is shortened.
• Many biological men also have facial feminization surgery to change the appearance of their lips, eyes, nose, or Adam’s apple.
• After surgery, patients use  vaginal dilators  to keep the new vagina open and flexible.
• Surgery for females transitioning to males is more complicated and expensive. The breasts, ovaries, and uterus are removed and the vagina is closed. A penis and scrotum may be made from other tissue. In some cases, a penile implant is used. The urethra is extended so that the patient can urinate while standing.

Continued psychotherapy is recommended for most patients as they adjust to their new bodies and lifestyles.

Not all people with gender dysphoria have surgery. Some feel comfortable living as the opposite gender without medical intervention. Others find that hormone therapy is sufficient for their personal needs.

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Gender transition is different for each person. There aren’t any specific steps required for someone to transition — it’s all about what feels right for you. It’s sort of like a buffet, where you can try everything, a few things, or nothing at all. Also, you may not want or have access to some kinds of transition.

What does it mean to transition?

Transitioning is about making changes so that you can live in your gender identity . These changes can include changing your name or getting gender-affirming medical care . People often transition to reduce gender dysphoria and/or increase gender euphoria . 

How long does transitioning take?

Transitioning isn’t necessarily a straight line or direct route. Transitioning can be a long and ongoing process, or it can happen over a short period of time. You might try out different things as you learn what’s best for you.

The transition process is about becoming more fully yourself — in body, mind, and relationships. So, people sometimes call transitioning “congruence.”

How do I start  transitioning?

You can start by learning about the different areas of transition, or ways to affirm your gender : 

• physical (medical and non-medical) 

Internal transition changes the way you see yourself.

You might try dressing differently when you’re by yourself, calling yourself by a different name only in your head, or practice using your voice differently. You might start to notice times that you feel gender dysphoria or gender euphoria. Other people might not know about or be able to see this kind of transition. 

Social transitioning may include things like:

• coming out to your friends and family as transgender or nonbinary; 
• asking people to use pronouns that feel right for you;
• going by a different name;
• dressing/grooming in ways that feel right for you when other people can see you; and 
• using your voice differently when talking to other people.

Legal transition changes information about your gender in official records and government documents.

While the laws vary in different states, you might legally change your name and/or gender marker on formal records, like:

• your driver’s license, state ID, or passport; 
• your birth certificate;
• your social security number;
• your immigration documents, permanent resident card, or naturalization certificate;  
• with your school or employer; and 
• with your doctor or health insurance.  

Some kinds of legal transition require paperwork and can be expensive. Some can be free and pretty easy. It depends on where you live and what you want to change.

Learn how to change your name and/or gender marker on legal documents at the  National Center for Transgender Equality .

Physical transition is about changing your body, either temporarily or permanently, to line up with your gender identity.

Non-medical physical transition includes ways that you can temporarily change your body without a doctor’s help. They're often low-cost or free. They include:

• chest binding , using clothing like binders or sports bras to flatten your chest; 
• stuffing , using materials like a padded bra, padded underwear, or tissue paper to make your chest, hips, or butt look fuller;
• tucking , hiding your penis and/or scrotum to make your groin flatter; and 
• packing , using items like a packer, cup, or balled-up socks to give your groin a bulge.

All of these strategies are temporary. So, someone can do them regularly, for special occasions, just one time, or while they wait to access medical transition.

Medical physical transition — longer lasting ways to transition — include working with a nurse or doctor.

For trans men and some nonbinary people, medical transition may include any of the following:

• gender-affirming hormone therapy : taking hormones to develop secondary sex characteristics such as a deeper voice, facial hair growth, muscle growth, redistribution of body fat away from hips and breasts, and not getting a period;
• mastectomy, also called “ top surgery :” the removal of breasts and breast tissue;
• voice training: working with a professional to learn to use your voice differently;
• laryngoplasty: surgery that changes your vocal chords; 
• hysterectomy : the removal of internal reproductive organs such as the ovaries and uterus;
• phalloplasty : construction of a penis using skin from other parts of your body;
• metoidioplasty : surgery that makes your clitoris longer and more flexible, like a penis;
• scrotoplasty: surgery that creates a scrotum and testes;
• vaginectomy or vulvectomy: surgery that removes your vagina and/or vulva — commonly combined with other genital surgeries; 
• nullification: surgery that hides or removes all external genitals, like the clitoris or vulva, to create a smooth groin; and 
• fertility preservation: saving eggs that can be used to have biological children in the future.

For trans women and some nonbinary people, medical transition may include any of the following:

• gender-affirming hormone therapy: taking hormones to develop secondary sex characteristics such as breasts, redistribution of body fat toward hips and breasts, and less body hair;
• breast augmentation: also called “ top surgery ” (aka implants);
• laryngoplasty: surgery that changes your vocal cords; 
• laser hair removal: removing hair from your face, neck, or other parts of your body;
• tracheal shave: making your Adam’s apple smaller;
• facial feminization surgery: surgeries that change the shape and/or size of parts of your face, like your nose, lips, cheeks, or jaw;
• orchiectomy : removal of testes;
• vaginoplasty : creation of a vagina, often by inverting the skin of the penis;
• nullification: surgery that hides or removes all external genitals, creating a smooth groin; and 
• fertility preservation: saving sperm that can be used to have biological children in the future.

Gender-affirming medical procedures vary in cost and availability. Some procedures might be covered by your insurance , and others might not be. This depends a lot on where you live and what kind of medical care you can access.

Do people transition in different ways, orders, and paces?

Yes. For example, you could transition socially without wanting any medical procedures. You could transition medically by doing one or only a few of the procedures listed above. You could change your name and gender marker on formal records. You might transition internally and not feel ready to or not want to transition in other ways.

Do all trans and nonbinary people transition?

No. Transitioning is not a requirement for being trans, nonbinary, or any gender identity. Not all trans people want the available medical procedures or other ways of transitioning.

Access to resources and support also shapes whether you transition. Medical procedures can be expensive, and not everyone has the money or health insurance coverage to afford them.

Transgender people who don’t transition at all, or don’t transition in certain ways, are just as real as those who do. Someone’s gender identity should always be respected.

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Gender Reassignment

• Equality, Diversity & Inclusion
• ED&I at Cambridge
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• Guidance on Gender Reassignment for Staff
• Sexual Orientation

Gender reassignment is a protected characteristic and the term refers to someone who is transgender. It includes anyone who has proposed, started or completed a process to change his or her sex. The Equality Act extends pre-existing protections for transsexual people by, for example, prohibiting indirect discrimination and removing the need for a transsexual person to be under medical supervision to benefit from legal protection. In employment, the Act also requires organisations to treat absences from work because someone proposes to undergo, is undergoing or has undergone gender reassignment in the same way or better as absences due to illness or injury.

There is limited data on the number of transgender people working or studying in the University. It is believed that there are likely to be more transgender people in higher education than in the population at large.

• A colleague who was born female decides to spend the rest of his life living as a man. He tells his departmental administrator, who makes appropriate arrangements. He then starts life at work and home as a man. After discussion with his doctor and a Gender Identity Clinic, he begins hormone treatment and several years later he has gender reassignment surgery. In this case he would be protected by the gender reassignment provisions of the Equality Act. His departmental administrator should seek guidance from the School's Human Resources Business Manager who will be able to provide support in managing the transition process.
• A student who was born physically male decides to spend the rest of her life as a woman. She starts and continues to live as a woman. As she successfully ‘passes’ as a woman, the student decides that she does not want to seek medical advice nor undergo any medical procedure/treatment. She would similarly be protected by the gender reassignment provisions of the Equality Act.

Support is provided to Transgender staff members of the University, College or associated institution through the LGBT Staff Network.

Support for Transgender Students is provided by the CUSU LBGT Campaign .

The University has produced Guidance on Gender Reassignment for Staff which provides information on good practice to support staff and institutions in implementing the University's Equal Opportunity Policy in relation to gender reassignment.

The University has produced Thinking Globally , which provides information for LGB&T staff and students working and studying at home and abroad.

Additional information and guidance is available from the Equality, Diversity and Inclusion Section.

The ECU has produced revised guidance on Trans Staff and Students in Higher Education .

The University has produced a glossary to explain terms related to gender reassignment.

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gender reassignment

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

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Example sentences.

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

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Meaning of gender reassignment in English

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to move the pedals (= parts you operate with your feet) backwards on a bicycle

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• Gender dysphoria

Your health care provider might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. Your provider will also ask about the degree of support you have from family, chosen family and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. It involves feelings of distress due to a strong, pervasive desire to be another gender.

Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Others might instead show symptoms of a mood disorder, anxiety or depression. Or they might experience social or academic problems.

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Our caring team of Mayo Clinic experts can help you with your gender dysphoria-related health concerns Start Here

Treatment can help people who have gender dysphoria explore their gender identity and find the gender role that feels comfortable for them, easing distress. However, treatment should be individualized. What might help one person might not help another.

Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of gender-diverse people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the chest, external genitalia, internal genitalia, facial features and body contour

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair.

Treatments are based on your goals and an evaluation of the risks and benefits of medication use. Treatments may also be based on the presence of any other conditions and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Legal age in a person's country or, if younger, following the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pre-treatment medical evaluation is done by a doctor with experience and expertise in transgender care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments This evaluation may include:

• A personal and family medical history
• A physical exam
• Assessment of the need for age- and sex-appropriate screenings
• Identification and management of tobacco use and drug and alcohol misuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo or ovarian tissue cryopreservation
• Documentation of history of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria.

The goal of behavioral health treatment is to help you feel comfortable with how you express your gender identity, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couples, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of the stress that results from experiencing prejudice and discrimination because of your gender identity (minority stress)
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A behavioral health evaluation may not be required before receiving hormonal and surgical treatment of gender dysphoria, but it can play an important role when making decisions about treatment options. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance misuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

More Information

Gender dysphoria care at Mayo Clinic

• Pubertal blockers
• Feminizing hormone therapy
• Feminizing surgery
• Gender-affirming (transgender) voice therapy and surgery
• Masculinizing hormone therapy
• Masculinizing surgery

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Mental health care. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about any anxiety or depression you're experiencing.
• Support groups. Talking to other transgender or gender-diverse people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritizing self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditation or prayer. You might find comfort and support in your spirituality or faith communities.
• Getting involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for your appointment

You may start by seeing your primary care provider. Or you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms , including any that seem unrelated to the reason for your appointment
• Key personal information , including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your health care provider
• Ferrando CA. Comprehensive Care of the Transgender Patient. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Hana T, et al. Transgender health in medical education. Bulletin of the World Health Organization. 2021; doi:10.2471/BLT.19.249086.
• Kliegman RM, et al. Gender and sexual identity. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Ferri FF. Transgender and gender diverse patients, primary care. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Nov. 8, 2021.
• Keuroghlian AS, et al., eds. Nonmedical, nonsurgical gender affirmation. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Nov. 8, 2021.
• Coleman E, et al. Surgery. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Version 7. World Professional Association for Transgender Health; 2012. https://www.wpath.org/publications/soc. Accessed Nov. 3, 2021.

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Definition of gender reassignment noun from the Oxford Advanced Learner's Dictionary

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Before Nigel Farage entered the fray yesterday, Kemi Badenoch’s declaration that a newly elected Conservative Party would rewrite the Equality Act was the highlight of the UK General Election campaign. At very least, the promise to protect single-sex spaces by making ‘biological sex’ a protected characteristic put some clear water between the Tories and the Labour Party, which hastily labelled Badenoch’s intervention ‘ a distraction ’. As Lauren Smith has pointed out on spiked , Labour Party higher-ups might be happy to disregard sex-based rights, but they really do matter to women. Still, the Conservative Party’s talk of reforming the Equality Act now, having failed to act while in office, rings hollow.

Back in 2010, the newly elected Conservative-Liberal Democrat coalition inherited the Equality Act from the previous Labour regime. It was one of the final pieces of legislation from the New Labour era. It came about after years of campaigning by activists and human-rights organisations. It brought together numerous existing laws such as the Equal Pay Act 1970, the Sex Discrimination Act 1975 and the Race Relations Act 1976. The new combined act offered legal protection against discrimination on the basis of nine ‘ protected characteristics ’, including sex, race, disability, pregnancy and religion. It also defined discrimination as direct or indirect, and specified that this could include harassment and victimisation on the basis of these characteristics.

The Equality Act represented a shift from ‘formal’ to ‘substantive’ notions of equality. In other words, it passed into law the contested notion that equality does not mean treating people identically, but is instead about accommodating differences. This legal expectation was first introduced with the Sex Discrimination Act 1975 and a similar approach was adopted in relation to race from 2000, following the inquiry into the death of Stephen Lawrence . This move from equal treatment to what is now often called ‘equity’ was then formalised by the Equality Act.

The Equality Act did more than just expand definitions of ‘equality’ and ‘discrimination’. It offered legal protection to groups not previously covered by legislation. Most controversially, this included the protected characteristic of ‘gender reassignment’. A decade and a half ago, it was assumed that only a tiny number of people would seek gender-reassignment surgery and medically transition from one gender to another. Notably, the Equality Act does not offer protection for ‘transgender people’ as a distinct group. The thinking was that, post-transition, males would receive the protections afforded to women, and females who presented as men would not need any additional protections. The notion that large numbers of people would ‘self-identify’ as members of the opposite sex, especially without seeking a gender-recognition certificate, was back then unimaginable.

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The world has changed significantly since the Sex Discrimination Act and the Race Relations Act were introduced in the 1970s, and even since the introduction of the Equality Act just 14 years ago. Go back five decades and you find trade unions striving to keep women and ethnic-minority workers out of better paying jobs. Women were routinely sacked by their employers for becoming pregnant .

It is, of course, good news that sexism and racism are no longer prevalent. But the emergence of today’s woke capitalism has brought its own problems. Employers are now expected to make clear that they are actively anti-racist, anti-sexist and pro-LGBT rights. Diversity targets have been implemented so zealously that even organisations like the Royal Air Force have been found guilty of discriminating against white men. Diversity officers have replaced personnel managers and they are more likely to work with, rather than be pitched against, trade-union officials in promoting ‘equality, diversity and inclusion’ (EDI) initiatives. In today’s workplace, pronoun badges, anti-racism workshops and unconscious-bias training allow managers unprecedented control over not just the time of employees, but also their consciences. Such initiatives divide workers and undermine solidarity.

The Equality Act 2010 has become the legal justification for the proliferation of EDI rules and training sessions in the workplace. Perhaps made fearful by campaigning organisations such as Stonewall, managers strive to be proactive in challenging indirect discrimination before it ever arises. Businesses and public-sector organisations, such as the NHS and local councils , have felt justified in spending huge sums of money on employing EDI officers or promoting woke projects, even though the Equality Act 2010 does not specify that any of this is necessary. Some local authorities spend very little on EDI and do not fall foul of the law. Yet for employers motivated to introduce such measures, the Equality Act provides ample justification for their actions.

None of this is new. Yet for 14 years, the Conservative government has not dared to challenge the Equality Act. Indeed, rather than abolishing the legislation altogether, or at the very least attempting fundamental reform, the Tories have, at times, embraced the thinking behind it. Former prime minister Theresa May sought to make it easier for people to change gender , which would force women to accommodate men in their spaces. Conservative MP Caroline Nokes has argued that going through the menopause should be included as a protected characteristic under the Equality Act. When advocacy groups like Stonewall routinely over-interpreted the Equality Act in order to reorganise workplaces in line with trans ideology, Conservative ministers did little to rein them in. Even now, sections of the Conservative Party are berating Badenoch’s proposal to clarify the Equality Act for fuelling a ‘culture war’.

The dizzying dishonesty of Keir Starmer

In response to 14 wasted years, tinkering with the definition of ‘sex’ is not enough. The Equality Act has outlived its purpose and needs to be scrapped altogether. Unfortunately, the Labour Party seems opposed even to minor reforms . As one of the last pieces of legislation passed by Labour when it was previously in office, it provides a good indication of what we can expect under a Keir Starmer government. We already know that Labour proposes to ‘ simplify ’ the process of changing gender and has promised to introduce a Race Equality Act to gold-plate EDI practices. These proposals will further undermine women’s rights and sow more social division.

In an age of identity politics and woke capitalism, the Equality Act is not just unnecessary – it has become a barrier to solidarity and equal rights.

Joanna Williams  is a  spiked  columnist and author of  How Woke Won . She is a visiting fellow at  MCC Budapest .

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Transgender athletes may have to compete with their biological sex under Tories' proposed shake-up of Equality Act, says Kemi Badenoch

The shake-up of the Equality Act, which could result in transgender women being barred from female-only spaces, was mooted by equalities minister Kemi Badenoch earlier this year.

Political reporter @fayebrownSky

Monday 3 June 2024 09:41, UK

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Transgender athletes may have to compete alongside their biological sex under the Conservatives' plans to "clarify" equality laws, Kemi Badenoch has said.

The cabinet minister told Sky News her party is "not giving instructions" to different sporting bodies, but rather "making it very clear what the law is, that there is a difference between identifying as a different gender and what your biological sex is".

Election latest: Exclusive Sky News poll to give Commons projection

As part of their latest election offer, the Tories last night pledged to change the Equality Act to define the protected characteristic of sex as "biological sex".

In the past, critics have accused the Conservatives of seeking to stoke divisions and demonise transgender people in the search for votes - with concerns raised about what this could mean for sport and access to female-only spaces.

Asked what the law would mean in practice for transgender athletes, Ms Badenoch said it would not bar them from competing but in some cases they "may have to compete with their biological sex".

She said: "We believe that sports is something where there are sex categories for a specific reason.

"People compete in women's sports because they're biological women, not because they identify as women. It is for sporting bodies to be able to manage that.

"Transgender athletes are not stopped for competing. They may, in some cases, have to compete with their biological sex."

Asked which toilets the government intends for transgender people to use, Ms Badenoch said: "We have not said that transgender people can't use specific toilets. What we have said is that they [businesses] must provide toilets for single sexes as well.

"And if you provide for all, that is genuine inclusion. The sort of inclusion that people are doing are actually exclusive to women."

The Equality Act currently states that an individual must not be discriminated against on the basis of their sex.

Ms Badenoch, the women and equalities minister, stressed the reforms would not be a "change", but rather "re-emphasising what should be the status quo".

"Sex and gender were used interchangeably," she said. "What we're doing is making sure that people understand what the law says. We've seen a lot of problems with people misinterpreting the law."

Challenged about why the government hasn't already made the change if it was such a big problem, Ms Badenoch said the "biggest reason" was because the SNP's controversial gender recognition legislation "took up quite a lot of bandwidth".

Ms Badenoch first mooted the idea in April last year after writing to parliament's human rights watchdog for advice about it.

At the time, LGBTQ+ charity Stonewall said the proposal risked "opening yet another chapter in a manufactured culture war that will see little benefit to women, cis and trans alike".

Keep up with all the latest news from the UK and around the world by following Sky News

Labour said it would not amend the Equality Act if elected because there are already provisions to protect single-sex spaces, so the government's plans are "not needed".

Speaking to Times Radio, shadow defence secretary John Healey said: "What is needed is clearer guidance for service providers, from the NHS to sports bodies, and in prisons, on what single-sex exemptions need to be, and the best way to be able to do that is in guidance, not primary legislation."

The Lib Dems accused the Tories of waging "phoney culture wars" while Lee Anderson, the former Tory deputy chairman turned Reform candidate , called it "madness".

Announcing the pledge last night, Prime Minister Rishi Sunak said the safety of women and girls "is too important to allow the current confusion around definitions of sex and gender to persist".

Ms Badenoch, who has spoken frequently in the Commons on the issue, said the change in the law needs to occur because public bodies are now acting out of "fear of being accused of transphobia".

Read more from Sky News: Police review Tory candidate's adverts Poll to reveal projected winner of election

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The Conservatives said the proposed change to the law will not remove the existing and continuing protections against discrimination on the basis of gender reassignment provided by the Equality Act.

The sex of those with a Gender Recognition Certificate will still align with their acquired gender in law outside the Equality Act, for example, marriage law, as is the status quo.

Under the proposed scheme, the Conservatives will also establish in law that gender recognition is a reserved matter, as they say "this will mean that an individual can only have one sex in the eyes of the law in the United Kingdom".

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The Biden Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA

Lindsey Dawson , Laurie Sobel , Kaye Pestaina , Jennifer Kates , Samantha Artiga , and Alice Burns Published: May 15, 2024

This brief provides an overview of the Biden Administration 2024 final rule implementing Section 1557 of the ACA, which is home to the law’s major nondiscrimination provisions. While Section 1557’s protections took effect when the ACA was enacted in 2010, much of its reach has been determined by implementation guidance issued across different Presidential administrations, often reflecting conflicting views. The final rule reinstates and expands upon many of the 2016 regulations from the Obama Administration and is a reversal from much of the 2020 Trump Administration rule. We provide a brief background on 1557 rulemaking and identify key differences between this rule and the 2020 rule. We also highlight two areas of growing interest impacted by the rule – nondiscrimination protections for pregnancy related decisions, past, present and future, including abortion, and for transgender people. Despite the issuance of the final rule, debates about 1557’s protections, and ensuing litigation, continue and will be particularly dependent on the outcome of the 2024 Presidential election.

Introduction

On April 27, 2024, the Biden Administration’s Department of Health and Human Services (HHS) finalized long-awaited revised regulations implementing Section 1557 of the Affordable Care Act (ACA). Section 1557 prohibits discrimination on the basis of race, color, national origin, age, disability, or sex and applies to health programs and activities receiving federal financial assistance (referred to as covered entities). In broad terms, it prevents covered entities from discriminating against certain protected groups in providing health care services, insurance coverage and program participation. The rule has staggered effective dates starting on July 5, 2024. In broad terms, 1557 provides nondiscrimination health care protections to individuals in protected groups, including prohibiting denial of benefits, coverage, program participation, and otherwise unequal treatment based on these factors

The administration also released a FAQ and press release . Section 1557 houses the law’s major nondiscrimination provisions by incorporating protections from existing civil rights laws. These laws include Title VI of the Civil Rights Act of 1964 (race, color, and national origin), Title IX of the Education Amendments of 1972 (sex), the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973 (disability). Notably, Section 1557 is the first federal civil rights law to prohibit discrimination on the basis of sex in health care.

Section 1557’s protections took effect when the ACA was enacted on March 23, 2010, but much of the law’s reach has been determined by implementation guidance issued by different Presidential administrations, reflecting different interpretations  and  priorities. Across the Obama, Trump, and Biden administrations, the 1557 implementing regulations have volleyed back and forth in their interpretations, particularly related to the scope of entities covered by the law and the law’s ability to provide nondiscrimination protections based on sexual orientation and gender identity and pregnancy related conditions. These debates, and ensuing litigation, are likely to continue, and will be particularly dependent on the outcome of the 2024 Presidential election.

Most of the implementing regulations in the new rule are effective 60 days (July 5, 2024) after publication in the Federal Register (May 6. 2024). Some provisions impacting health insurance plan design won’t become effective until the plan year beginning after January 1, 2025, and other provisions where entities might need additional time to amend current practices also have later effective dates. (The rule and the FAQ provide a table of these dates.)

The FAQ accompanying the rule states it was necessary to issue this guidance “to restore and strengthen civil rights protections for individuals consistent with…the statutory text,” noting that the 2020 Trump Administration rule “covers fewer programs and services and limited nondiscrimination protections for individuals.”

Section 1557 has been subject to a wave of litigation across administrations. Litigation has both centered on rulemaking and on the statue itself. In some cases (e.g. Franciscan Alliance v. Azar ), courts have found narrowly in favor of plaintiffs who have asserted that the requirement to cover or provide certain services, such as those related to termination of pregnancy or gender affirming care, violated their sincerely held religious beliefs and thus religious freedom protections. In other cases, courts have found that Section 1557 protects access to these same services, such as by requiring state Medicaid programs to cover gender affirming care (e.g. Flack v. Wisconsin ). Courts have also weighed in on the legality of aspects of rulemaking (e.g. Whitman-Walker Clinic v. HHS ) and litigation has already been filed in the state of Florida by the attorney general and a Catholic hospital group challenging the new rule (see State of Florida et al v. HHS et al . )  In addition, litigation related to other civil rights protections ( Bostock v Clayton County, Georgia) has implications for Section 1557 and, in particular, this regulation’s interpretation of nondiscrimination based on sex. (Box 1)

Box 1: Impact of Bostock v Clayton County, Georgia on Section 1557

In June 2020, just three days after the Trump Administration rule was finalized, the Supreme Court ruled in  Bostock v Clayton County, Georgia that in the context of employment, discrimination based on sex encompasses sexual orientation and gender identity. The Bostock ruling does not directly apply to 1557 because it was based on interpretation of sex protections under Title VII and the 1557 sex protections are pulled in through Title IX. However, courts have historically looked to Title VII in interpreting Title IX, including in cases where plaintiffs challenged the Trump-era rule. As such, prior to issuing the new regulation , the Biden Administration issued guidance in May 2021 stating it would interpret and enforce 1557’s sex nondiscrimination provisions to include protections on the basis of sexual orientation and gender identity in light of and consistent with Bostock .

Summary of Major Changes

The final rule closely mirrors a proposed rule  issued by the Biden administration in July of 2022 and is, in many ways, a reversal of the final rule issued by the Trump Administration in June of 2020, which itself was a significant departure from the Obama Administration regulations issued in 2016. This  final  rule reinstates and expands upon much of those 2016 regulations. Compared to the previous rules, key changes in the Biden Administration final rule include:

• Section 1557 applies to health programs or activities that receive direct or indirect federal financial assistance from HHS, health programs and activities administered by HHS, and Therefore, covered entities include state Medicaid agencies, Medicare, many health insurance plans, and most hospitals and providers, among others. The new rule expands on the types of entities subject to 1557 compared to the Trump rule, including by determining that 1557 protections apply to products sold by issuers with plans on the marketplaces (not just the marketplace plans themselves) and by considering Medicare Part B as receiving Federal financial assistance for the first time;
• Provides nondiscrimination protections for those who experience discrimination on the basis of multiple protected characteristics. (A new protection compared to both the Obama and Trump rules);
• Explicitly provides for nondiscrimination protections based on gender identity and sexual orientation, sex characteristics (including intersex traits), and pregnancy related conditions including pregnancy termination, as well as related specific health insurance coverage protections, expanding these moderately compared to the Obama rule and completely compared to the Trump rule;
• Provides specific nondiscrimination protections for transgender people’s access to care and coverage, expanding moderately on those in the Obama rule and completely compared to the Trump rule. The rule requires people be treated consistently with their gender identity, prohibits the denial of gender affirming care when provided for other purposes, if the denial is on the basis of sex, and the categorical exclusion of gender affirming care. (See box 3 for additional details related to this provision);
• Protects patients from discrimination on the basis of actual or perceived abortions but states it is not a violation of Section 1557 if providers do not provide abortions unless the provider does not do so based on an individual’s protected status (e.g. race, age, etc.) (See box 2 for additional details related to this provision);
• Removes explicit blanket abortion and religious freedom exemptions which the Trump rule incorporated through Title IX’s religious exemptions, stating instead that robust religious freedom protections exist outside of Section 1557 and that incorporation of Title IX exemptions through the rule is not necessary;
• Adopts a new religious freedom and conscience protections exemptions process;
• The new rule reinstates explicit prohibitions on discrimination based on gender identity and sexual orientation that had existed in ten other federal regulations outside Section 1557. The protections were put in place through Obama Administration regulations and related to coverage, access, and marketing, in Medicaid, private insurance, and the Marketplaces but were eliminated in the Trump Administration’s 1557 rule.;
• Expands protections for those with limited English proficiency (including in telehealth) compared to both prior rules;
• Includes new provisions for services requirements and notices related to language access and access to auxiliary aids and services, and adopts new policies and staffing requirements for 1557 compliance;
• Reaffirms most requirements related to disability discrimination from the 2016 rule, which complement a new rule on web accessibility for public entities under the Americans with Disabilities Act and major updates to regulations implementing Section 504 of the Rehabilitation Act, which were last updated in 1977. Section 504 prohibits recipients of federal funding, including publicly-subsidized health payers and health care providers who accept Medicare or Medicaid, from discriminating against people on the basis of disability. Among other changes, the Section 504 health provisions address discrimination in medical treatment, create enforceable standards for medical equipment, address accessible web content and mobile apps, and codify the Olmstead requirement to serve people with disabilities in the most integrated setting that is appropriate.
• Reflecting emerging technologies, for the first time, addresses and applies Section 1557 nondiscrimination protections to the use of telehealth and patient care decision support tools, including in addressing bias in clinical algorithms and other tools and in the use of AI.

Box 2: Abortion – Protections from Sex Discrimination Includes Pregnancy Termination

The ACA protects providers and programs based on their willingness to provide, pay for, cover, or refer for abortion or to provide or participate in such trainings. The new final Section 1557 rule includes protections for patients on discrimination on the basis of having had actual or perceived abortions. OCR explains that a covered provider’s decision not to provide an abortion is not a violation of Section 1557 unless the provider chooses not to provide abortion for a particular individual based on a protected ground such as race. Some commenters “expressed concern that Dobbs created tension between health providers, and patients, increasing distrust in providers and that it has created chaos in the health care system. They state this has increased the risk that patients will experience discriminatory care and suffer delays in lifesaving treatment as a direct result of legal and medical uncertainty. These commenters said that discrimination in care propagates more distrust, which is a significant barrier for individuals seeking care and is precisely what section 1557 was designed to protect against.” OCR responded to these concerns noting that it is considering revisions to the HIPAA Privacy Rule to strengthen privacy protections for individuals’ protected health information related to reproductive health care.

Box 3: Care and Access for Transgender People – Protections from Sex Discrimination Include Gender Identity

Section 1557’s regulatory treatment of sexual orientation and gender identity has changed considerably over time. The 2016 Obama Administration rule interpreted sex nondiscrimination protections to include gender identity and sex stereotyping (among other identities) but not sexual orientation. At that time, HHS stated it would “evaluate complaints alleging sex discrimination … sexual orientation” on a case-by-case basis and anticipated that case law would evolve as to clarify whether sexual orientation could be covered. The Trump Administration did not define sex in the regulatory text but in the preamble suggested it would interpret sex to mean only biological sex assigned at birth. The Biden Administration interpreted sex to include sexual orientation and gender identity (among other identities), reaffirming its earlier guidance which took the same approach, in light of Bostock (see Box 1). It also extends these protections to include intersex people for the first time.

As noted above, the new rule also reinstates explicit prohibitions on discrimination based on gender identity and sexual orientation in regulations outside of Section 1557 that had been put in by the Obama Administration but eliminated through the Trump Administration’s 1557 rule.

In addition, the rule, in text and preamble, spells out specific protections for transgender people and access to gender affirming care including that entities cannot refuse gender affirming care services that would be provided to an individual for other purposes, if the limitation is based on sex or gender and that the categorical exclusions of gender affirming care is prohibited. It does not prohibit nondiscriminatory denial of services with the preamble noting “OCR has a general practice of deferring to a clinician’s judgment about whether a particular service is medically appropriate for an individual, or whether the clinician has the appropriate expertise.” OCR states any investigations will not focus on clinical judgment per se but rather whether that judgment reflects unlawful bias, The rule also does not prevent a covered entity from availing itself of religious freedom and creates new pathways for asserting such protections. (Additional details in Table 1.)

Some commenters had specific concerns regarding the rule’s application to “State laws that prohibit access to gender-affirming care…” OCR responded that “some States may have laws…that are contrary to the final rule’s nondiscrimination protections, and…section 1557 preempts those laws.” The conflict between state and federal law in this case is unresolved and the Florida Attorney General, along with a Catholic medical group, has filed suit alleging that the rule requires providers to provide gender affirming care and violates protections.

Table 2 summarizes the major provisions of HHS’s new final rule and provides a side-by-side comparison to the Obama (2016) and Trump (2020) administration rules.

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• The Trump Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA and Current Status
• Summary of HHS’s Final Rule on Nondiscrimination in Health Programs and Activities

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