gender reassignment surgery cost in germany

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Gender Surgeons in Germany

Dr. juergen schaff.

Dr. Schaff offers gender reassignment surgery in Germany, both MTF and FTM procedures, including the fibula flap phalloplasty.

Dr. Laszlo Szalay

Dr. Klaus Exner

Dr. michael sohn, dr. tobias s. pottek, dr. ute ebert, dr. hendrik schöll, dr. susanne morath, dr. jens christian wallmichrath.

Dr. Robert Kampmann

Dr. markus krankenhaus, dr. cornelius klein, dr. wolf j. holtje, dr. wolfgang muhlbauer, dr. hans-georg luhr, dr. hans-peter howaldt, dr. cvetan taskov, dr. michael krueger, dr. jutta krocker, dr. andree faridi, dr. marcus küntscher, dr. jens diedrichson.

Dr. Wolfgang Funk

Dr. kay arne klemenz.

Transsexuality

Male is male and female is female! This is true for the vast majority of us – despite all individual differences. That is why hardly anyone can imagine what it means when this is not the case. In fact, according to estimates, at least 0.005% of all people are born in the “wrong body”. The reasons that lead to transsexuality (transidentity) are not yet finally researched, but much speaks for genetic (hereditary) causes.

Life as a transsexual person For those affected, transsexuality often means severe psychological suffering, exclusion from society, as well as a long and painful path to the long-awaited surgical gender reassignment.

Transgender surgery at Klinik Sanssouci Surgical gender reassignment procedures have been performed at Klinik Sanssouci for over 20 years.

While many clinics perform these gender reassignments in several individual surgeries, we prefer that the respective steps required for gender reassignment are combined in a single surgery (“All in One”). This reduces the duration of the entire gender reassignment and healing process.

This requires not only careful organization before, during and after surgery, but also the coordination of multiple surgical teams, as the individual surgical steps must be perfectly coordinated.

Due to the large number of gender reassignment surgeries that have already been performed at our clinic, Klinik Sanssouci can look back on a considerable amount of experience in this area – from preventive care to aftercare:

The pre-operative discussions, the preliminary examinations as well as the inpatient and also outpatient aftercare also take place in our clinic. In addition, our patients find support with many other questions on the subject of gender reassignment.

Our surgeons are renowned experts in their respective fields. After Dr. Paul Daverio, who has led the transgender surgery department from the beginning, moved to a new place of work at the age of 74 after his successful work with us, the medical leadership of the team has been in the hands of Dr. Olivier Bauquis from Lausanne, Switzerland, since 2018. Dr. Bauquis has been performing transgender surgeries for many years and accordingly has a great expertise and reputation.

In addition, we were able to gain Dr. Jürgen Schaff, another internationally renowned surgeon, for our clinic in 2020. Dr. Jürgen Schaff had previously performed man-to-woman operations in Munich at Klinikum Rechts der Isar with great dedication and success. In doing so, he has continuously refined the classical and well-known surgical methods and developed them into his so-called combined method.

We are very pleased to be able to offer our patients an even broader range of services in the field of TS surgery with two experienced specialists in transgender surgery.

Female-to-Male

Female-to-male surgery: phalloplasty Phalloplasty, penoid reconstruction as part of female-to-male (ftm) gender reassignment surgery, is arguably the most challenging and complex operation in the field of transsexual surgery.

The technique developed by Dr. Paul Daverio, in which the penoid (“artificial penis”) is formed in a microsurgical operation from skin and subcutaneous tissue including nerves and blood vessels of the forearm (so-called forearm flap), is nowadays considered the standard procedure for gender reassignment worldwide. It leads to the best optical and functional results and has been practiced at Klinik Sanssouci for over 20 years.

Surgical technique: The steps of surgical gender reassignment. Female-to-male surgical gender reassignment is performed under general anesthesia. This procedure takes about seven to nine hours and includes:

• the removal of the breasts (mastectomy)
• removal of the uterus (hysterectomy)
• removal of the ovaries and fallopian tubes (ovarectomy, adnectomy)
• removal of the vagina (colpectomy)
• the shaping of the penoid including the new urethra (neo-urethra)
• the plastic reconstruction of a glans (glansplasty)
• the lengthening of the female urethra with the labia minora
• the relocation of the penoid from the left forearm to the pubic area. The arteries (arteries) and veins (veins) of the penoid are connected to the corresponding blood vessels of the thigh. At the same time, the inguinal nerves are connected to the penoid nerves, as well as the lengthened urethra to the newly formed urethra.
• covering the tissue defect on the forearm with skin obtained either from the groin or from the excess skin of the breast.
• the preparation of the labia majora, where the artificial testicles will be implanted later.

Important: The clitoris (clit) remains at the base of the penoid and is not removed, only its covering epidermis. Thus, the ability to orgasm is preserved.

After the surgery

• After the surgery, intensive supervision with monitoring takes place. There will be several daily visits as well as regular dressing changes and wound inspections by our doctors.
• You may get up for the first time on the 6th day after the surgery.
• The bladder catheter is removed on the 12th day. From this moment on you can urinate standing up.
• Usually, you can leave the clinic on the 14th to 16th day.
• Further treatment after female-to-male gender reassignment can be performed by your doctors at your place of residence.
• Depending on your professional situation, you can expect to be unable to work for about 6 weeks.

Complications Female-to-male gender reassignment surgery, especially penoid reconstruction (phalloplasty), is a complex procedure and therefore prone to complications. At Klinik Sanssouci, complications occur with about 5% of our patients.

Possible complications of phalloplasty include:

Stenosis This is a constriction at the connection between the urethra and the newly formed urethra (neo-urethra). This complication can usually be corrected by simple bougienage (widening) by the urologist. Only in 1 to 2% of cases is a minor second surgery required, often under local anesthesia, to widen this constriction.

Fistula This is a connection between the urethra and the skin surface through which urine can leak out. Fistulas usually close spontaneously after two to three months. If this does not occur, the fistula can be closed in a minor procedure under local anesthesia. Serious complications such as complete penoid loss (flap loss) are very rare.

Erectile prosthesis / testicular replacement A second procedure is necessary if an erectile prosthesis is to be installed. This surgery is possible if there is feeling in the penoid, which is usually about eight to ten months after the phalloplasty surgery.

As erectile prosthesis we use a so-called hydraulic implant from American Medical Systems (AMS) with a pump (AMS 700), which is placed in the newly formed scrotum (neoscrotum). A reservoir is surgically placed under the abdominal wall muscles. We place two inflatable silicone rods into the penoid. An erection is then possible by means of this pumping system. We also implant silicone testicles in the scrotum.

Male-to-female

Surgical technique The surgical male-to-female sex adjustment is performed under general anesthesia and takes about 4-5 hours. If desired, we can perform augmentation at the same time (insertion of a silicone implant for breast augmentation or augmentation with autologous fat). At the same time, a thyroid cartilage reduction is also possible.

For sex adjustment, we offer two different methods (Classic penile inversion and combined method), both of which provide excellent results, but differ in several ways.

Classic penile inversion involves the following surgical steps:

Removal of the testicles (orchidectomy)

• plastic construction of a neovagina with an island flap plasty
• plastic construction of a sensitive neoclitoris
• plastic construction of labia from scrotum
• shortening of the urethra
• cavernous body removal
• plastic construction of pubic mound
• breast reconstruction if necessary
• if necessary, reduction of the thyroid cartilage

In the combined method, additional skin grafts and the original urethra are used to build up a neovagina. Due to the special incision in this method, a more natural vulvoplasty (plastic reconstruction of the labia) is possible.

The following surgical steps are performed:

• removal of the testicles (orchidectomy)
• plastic construction of a neovagina with a combined island flap plasty, free skin graft from the skin of the scrotum as well as pedicled urethral skin
• plastic construction of labia and clitoral hood from parts of penile shaft skin

Due to the special incision, a second surgery is mandatory for the combined method. This involves some fine plastic work that cannot technically be implemented in the first surgery. Usually, the desired breast augmentation and other optional plastic procedures are also performed during this second surgery.

In direct comparison, each method has its own strengths and weaknesses, which we will be happy to discuss with you in a personal consultation in order to select the optimal treatment strategy for you.

After surgery

• after the surgery, intensive supervision with monitoring takes place. There are several daily rounds as well as regular dressing changes and wound checks by our doctors
• you can already get up on the 1st day and also go to the toilet
• the urinary catheter is removed on day 6 to 8
• Usually you can leave the clinic on the 8th to 12th day
• further treatment after male-to-female gender reassignment surgery can be performed by your doctors at your place of residence
• depending on the professional situation, an inability to work of approx. 4 weeks is to be expected
• in the combined method, bougienage (dilatation) of the neovagina must be performed – written instructions for bougienage after discharge can be found here (PDF, 39k).

Complications Complications occur in less than 5% of our patients.

• postoperative bleeding approx. 1 %
• narrowing (stenosis) of the urethral opening 1-2 %
• narrowing (stenosis) of the neovagina approx. 1 %
• we were not able to record any serious complications
• in about 30% of our patients, we perform corrective surgery after about 3-6 months, when the vaginal entrance is constricted by a small fold formed during invagination (invagination) of the original penile skin.

Requirements

For female-to-male or male-to-female gender reassignment, the following medical as well as legal requirements are necessary at Klinik Sanssouci:

• You should have undergone opposite-sex hormone treatment for at least six to eight months.
• We also need two expert opinions from you that confirm your transsexuality (transidentity). These can be, for example, the expert opinions that you obtained as part of your change of first name and civil status.

Of course, we will be happy to advise you in a personal preliminary consultation about the exact procedure of the operation and answer your questions. You can make an appointment with us, please use our contact form.

Costs / Cost coverage

In general, a transsexual patient has the right to a gender reassignment surgery. Usually, this is not declined by the health insurances. However, there is no obligation for the statutory health insurance companies to cover the costs of treatment in a private clinic.

The vast majority of our transsexual patients have statutory or private health insurance and have been granted reimbursement for an operation in our clinic on a case-by-case basis. Private health insurances usually reimburse partial amounts. We will be happy to assist you with the application process. In particular, you will need a cost estimate from us, which you will receive from us during your consultation appointment.

International patients who have to pay their costs in advance as self-payers should also obtain a cost estimate.

Please feel free to contact us with any questions you may have regarding the details of reimbursement and billing.

Frequently asked questions

Female-to-male

What methods of phalloplasty do you use and what are the functional results? We perform phalloplasty with a so-called free forearm flap. The patient can urinate standing up after the operation on the 12th day. Sexual sensitivity is preserved because the clitoris (clit) is not removed in our method. All surgical steps are performed in one session.

Why do you perform all surgical steps in one session? This procedure, the all-in-one surgery, significantly reduces the duration of the entire inpatient stay, and of course also the number of surgeries. An essential consideration is also the rapid restoration of full working capacity. It is always claimed that the risks increase due to multiple surgery, but with careful organization, good teamwork and very great experience, it is possible to perform individual surgical steps with several surgical teams at the same time without extending the total surgical time. One-stage surgery also avoids scarring adhesions in the vaginal area, which are disadvantageous in a second operation. If the breast is removed at the same time, we can use the excess skin for coverage and, if necessary, do without other skin removal sites (fewer scars). Not to be forgotten are stress factors that are eliminated when the patient has to undergo surgery only once.

Do you work with microsurgery? Yes. In phalloplasty, the penoid is formed from skin and subcutaneous tissue, including nerves and blood vessels of the forearm (called the forearm flap) in a microsurgical surgery.

How many surgeries are necessary until a final result? At Klinik Sanssouci Potsdam, two surgeries are necessary for complete female-to-male gender reassignment: The first surgery includes removal of the uterus (hysterectomy), removal of the ovaries and fallopian tubes (ovarectomy, adnectomy), removal of the breast (mastectomy), removal of the vagina (colpectomy), and penoid reconstruction (phalloplasty). In a second surgery (about eight to ten months after the first surgery), an erectile prosthesis and a silicone testicle are implanted into the newly formed scrotum.

How long does a patient have to stay in the clinic? For the first surgery, during which the penoid reconstruction (phalloplasty) takes place, you will need to plan for about 14 to 16 days of hospitalization.

What is the sensitivity of the penoid (neophallus)? The sensitivity, i.e. the sensation of the penoid, corresponds to normal skin sensitivity, comparable to the sensitivity of the skin on the forearm. Sensitivity is achieved by the ingrowth of nerves about eight to ten months after the initial surgery. Some erotic sensitivity, starting from nerves of the clitoris, is also possible.

What happens to the clitoris? Will it be removed or how will this important organ be preserved? During the phalloplasty surgery we preserve the clitoris completely and with it the sensitivity and sexual experience. We achieve this by only removing (deepithelializing) the clitoris from its epidermis, placing it at the base of the penoid and only covering it with skin so that arousal is possible as before the procedure. We do not consider the removal of the clitoris to be useful.

Have serious problems occurred at the forearm collection site? No. In the first days and weeks after the phalloplasty surgery, the hand may swell a little and become thicker. Then you should keep it elevated. We also recommend regular exercise of the hand. Serious, for example motor (movement) problems have not occurred – even fine motor movements of the hand are not affected.

Where are scars found on the penoid and are they visible? The only scar that will be visible on the penis is on the back of the penoid, so it will not be visible from the front.

Is there an acorn buildup? And when does it take place? Yes, glans reconstruction (glansplasty) is performed as standard together with phalloplasty in the first procedure.

Will a sensitive clitoris be created and how is it done? Microsurgically, while preserving the blood vessels, a clitoris is constructed from a portion of the glans (penis) in such a way that it is sexually aroused and placed in a typical location.

Are additional surgeries performed at the same time and what are they often? If desired, we perform breast reconstruction, i.e. implantation of a silicone prosthesis, in the same session. If desired, a thyroid cartilage reduction is also possible. These procedures extend the total operation time only insignificantly.

Will follow-up procedures be necessary and how often? Due to invagination of the original penile skin for the construction of the neovagina, there is often a fold at the posterior vaginal entrance, which we leave intraoperatively in order not to endanger blood circulation and thus good healing of the penile skin in the pelvis. Therefore, in about 30% of our patients we perform a widening of the vaginal entrance about 3-6 months after the initial procedure. During this procedure, small labia are formed at the same time and, if desired, the clitoris is reduced in size. As a rule, the clitoris is created during the initial operation in such a way that the safety of blood circulation and sensitivity are ensured, so that for many patients the clitoris primarily appears to be somewhat large. This is corrected during the follow-up surgery.

Are other procedures performed in your clinic for optical adaptation to the female gender? Reduction of the larynx can be performed. Likewise, nose correction and other procedures from the repertoire of aesthetic plastic surgery are possible.

When is sexual intercourse possible after surgery? There is no set rule, but medically it is possible to have normal sexual intercourse about 6 weeks after surgery.

Where are visible scars found? There are scars only on the labia majora, which are formed by reduction of the scrotum.

At what point is vaginal dilatation possible and do you use a so-called stent? After surgery, a loose tamponade is inserted into the neovagina, which is replaced on the 5th to 6th day. Careful stretching with a small dildo is possible about 10 to 14 days after surgery. It is not necessary to use a stent.

Can there be problems with sexual intercourse after surgery? Every transsexual patient should keep in mind that the pelvis of a man is much smaller and narrower than usually the pelvis of a so-called biological woman. In addition, the pelvic floor muscles are usually more strongly developed and not as soft and stretchy as in bio-women. For these reasons, it is not uncommon for muscular constriction to occur, which can persist over a longer period of time and can also lead to difficulties during sexual intercourse. Consistent stretching and relaxation is helpful in this case.

Specialist in Plastic and Reconstructive Surgery

Specialist in Plastic and Aesthetic Surgery Hand Surgeon

Specialist in Gynecology and Obstetrics

Specialist in Surgery Specialist in Plastic and Cosmetic Surgery Specialist in Hand Surgery

Physician Assistant

Dr. med. Olivier Bauquis

www.olivierbauquis.ch

Specializations Transsexuality surgery

Range of Medical Services Gender reassignment surgery female-to-male and male-to-female

Contact / Consultation Hours Consultation Center Potsdam Helene-Lange-Straße 11 14469 Potsdam ✆ +49 (0) 331 280 87 200 🖷 +49 (0) 331 280 87 209 📧 [email protected]

More Information „Transsexualität: Im falschen Körper“ mit Dr. Olivier Bauquis (in German, SRF)

• Senior physician at the University Hospital of Lausanne, Switzerland
• Co-director of the transgender network Vaud-Genève since 2017
• Medical expert for transgender surgery
• Stays abroad: 2011, Montréal, Canada, Dr. P. Brassard: surgery of transsexuality 2014, Ghent, Belgium, Prof. S. Monstrey: surgery of transsexuality
• 2006 Start of specialization in surgery of transsexuality
• Conference president “Transsexualité” at the Women’s Health Congress, 2012
• Session chair: “Surgery of gender reassignment” at the annual congress of the Swiss Society of Surgery, 2013
• Article “Gender reassignment surgery” in the Swiss Med Forum (PDF in German, 921k)
• Article „Chaque semaine au CHUV un patient change de sexe“ in VAUD (JPEG in French, 803k)

Memberships

• Swiss Medical Association (FMH)
• Swiss Society for Hand Surgery
• Swiss Society for Plastic and Reconstructive Surgery
• European Society for Surgery of Transsexuality

Prof. Dr. med. Markus Küntscher

Specialist in PLASTIC AND AESTHETIC SURGERY Hand Surgeon

www.professor-kuentscher.de

Specializations Aesthetic surgery, breast reconstruction and transgender surgery

Contact / Consultation Hours Consultation in Private Praxis Hohen Neuendorf Wilhelm-Külz-Str. 32A 16540 Berlin ✆ +49 (0) 3303 81 69 11 ✆ +49 (0) 3303 212 30 55 📧 [email protected]

More information Interview at welt.de on the topic of liposuction for lipedema (in German)

• German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC)
• Association of German Aesthetic and Plastic Surgeons (VDÄPC)
• German Society for Surgery (DGC)
• German Society for Burns Medicine (DGV)
• German Society for Hand Surgery (DGH)

C.V. Prof. Küntscher (German)

Dr. med. Florian Müller

www.krankenhaus-waldfriede.de

Specializations Minimally invasive gynecological procedures

Contact / Consultation Hours Krankenhaus Waldfriede Gynäkologie, Haus A, 3. OG Argentinische Allee 40 14163 Berlin ✆ +49 (0) 30 81 810 245 oder ✆ +49 (0) 30 81 810 207 🖷 +49 (0) 30 81 810-77245 📧 [email protected]

More Information Chief Physician of the Department of “Gynecology and Obstetrics” at Waldfriede Hospital

Dr. med. Jürgen Schaff

www.drschaff.de

Range of Medical Services Male-to-female feminization surgery, feminizing breast surgery, facial feminization.

More Information

• 1988 Beginning of specialization in surgery of transsexuality
• Medical practice at the Klinikum Rechts der Isar TU Munich until 1994
• Chief physician at Amperklinikum Dachau until 2004
• Head physician Red Cross Clinic Munich and Praxisklinik until 2019
• 2006 Foundation of the Quality Circle Transsexuality in Munich with Dr. Werner Ettmeier, 3-4 events per year
• 2008 Foundation of a symposium for transsexual surgery, annual events at different locations
• Foundation of the Working Group Transsexuality of the German Society of Plastic Reconstructive and Aesthetic Surgeons
• Expert witness for transgender surgery
• Live surgeries at several hospitals in Germany and abroad
• Development of several new surgical techniques and surgical standards
• German Society for Surgery
• Association of German Aesthetic Plastic Surgeons (VDÄPC)
• Interplast Germany
• World Professional Association for Transgender Health (WPATH)

Priv.-Doz. Dr. med. Andreas E. Steiert

www.steiert.berlin

Specializations Surgery of transsexuality

Range of Medical Services Plastic surgery and microsurgery with a focus on gender reassignment surgery female-to-male and male-to-female

Contact / Consultation Hours Sprechstundenzentrum Potsdam Helene-Lange-Straße 11 14469 Potsdam ✆ +49 (0) 331 280 87 200 🖷 +49 (0) 331 280 87 209 📧 [email protected]

More information General surgery training at the Charité and the RWTH-Aachen.

Publications: Author of numerous publications on various topics in internationally renowned journals:

• Aesthetic Surgery Journal (Official Journal of The American Society for Aesthetic Plastic Surgery).
• Aesthetic Plastic Surgery Journal (Springer-Verlag)
• Journal of Biomedical Materials Type A
• Journal of Surgical Research
• Medical Devices
• Journal of Plastic, Reconstructive and Aesthetic Surgery

and is the author of several book chapters, including “Facelift” in “Praxis der Plastischen Chirurgie, edited by Prof. Peter M. Vogt, Springer Verlag.

10/2001 Clinic for Plastic, Hand and Reconstructive Surgery, Hanover Medical School Univ.-Prof. Dr. P.M. Vogt

06/2007 Appointment as senior physician of the clinic Clinic for Plastic, Hand and Reconstructive Surgery, Hanover Medical School Univ.-Prof. Dr. P.M. Vogt

04/2011 Appointment as Managing Senior Physician of the Clinic, Deputy of the Clinic Director Clinic for Plastic, Hand and Reconstructive Surgery, Hanover Medical School Univ.-Prof. Dr. P.M. Vogt

12/2012 Additional qualification in hand surgery

09/2015 Habilitation Award of the Venia Legendi for Plastic and Aesthetic Surgery

• International Confederation for Plastic Reconstructive & Aesthetic Surgery (IPRAS)
• German Society for Senology (DGS)
• German Society for Surgery (DGCH)
• Professional Association of German Surgeons (BDC)

Contact our transgender division

• What We Treat
• Consultation Center
• Anesthesiologists
• Physician Assistants
• Contact People
• [email protected]
• TEL 0331 – 280 87 0 FAX 0331 – 280 40 86
• Klinik Sanssouci Potsdam Helene-Lange-Straße 13 14469 Potsdam

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Medical Tourism

Best countries in the world for gender reassignment surgery.

Gender reassignment surgery (GRS) is a life-changing medical procedure that can help individuals align their physical appearance with their gender identity. Across the globe, various countries have gained recognition for offering top-notch GRS procedures, comprehensive healthcare, and experienced medical professionals. In this article, we will delve into the best countries in the world for gender reassignment surgery, shedding light on the remarkable destinations where individuals can embark on their transformative journey.

Thailand: Pioneering Excellence

Thailand has earned a reputation as a pioneer in gender reassignment surgery. Renowned for its world-class medical facilities and a cadre of skilled surgeons, Thailand offers a safe and comfortable environment for individuals seeking GRS. The country's medical tourism infrastructure is well-developed, with Bangkok serving as a hub for transformative surgeries.

Germany: Leading the Way in Europe

Germany stands out as a prominent European destination for gender reassignment surgery. The country boasts cutting-edge technology, rigorous medical standards, and an array of experienced surgeons. Berlin, in particular, is recognized for its excellence in GRS procedures, drawing patients from around the world.

United States: A Hub of Expertise

The United States, with its vast healthcare network and innovative medical centers, remains a popular choice for gender reassignment surgery. Cities like New York, San Francisco, and Los Angeles have world-renowned gender clinics that offer a wide range of procedures and comprehensive care.

Canada: A Compassionate Approach

Canada's inclusive healthcare system and commitment to LGBTQ+ rights make it a compassionate choice for gender reassignment surgery. Major cities like Toronto and Vancouver provide access to skilled surgeons and supportive medical facilities, ensuring patients receive top-tier care throughout their journey.

Brazil: Combining Beauty and Expertise

Known for its stunning landscapes and a reputation for cosmetic surgery, Brazil also shines in the realm of gender reassignment surgery. The country boasts experienced surgeons who are well-versed in GRS procedures, making it a sought-after destination for those seeking comprehensive transformations.

Belgium: Precision and Expertise

Belgium stands out as a hub for precision and expertise in GRS. The country's surgeons are renowned for their attention to detail, ensuring the best possible outcomes for patients. Brussels, the capital, is a prominent location for gender reassignment surgeries.

India: Affordable Excellence

For those seeking affordability without compromising on quality, India emerges as a viable choice for gender reassignment surgery. The country offers world-class medical facilities, experienced surgeons, and competitive pricing, making it an attractive option for international patients.

Argentina: Advocating Inclusivity

Argentina has made significant strides in advocating for LGBTQ+ rights and gender-affirming healthcare. Buenos Aires, in particular, boasts a thriving transgender community and skilled medical professionals who specialize in gender reassignment surgery.

South Korea: Excellence in Aesthetic

South Korea, renowned for its expertise in aesthetic procedures, has also gained recognition in the field of gender reassignment surgery. The country's commitment to precision and advanced medical techniques makes it a standout destination for those seeking facial feminization surgeries and other GRS procedures.

Embarking on a gender reassignment journey is a profound and life-changing decision. Choosing the right destination for gender reassignment surgery is crucial for ensuring a safe, supportive, and successful experience. The countries mentioned in this article have distinguished themselves as some of the best in the world for GRS, offering exceptional medical facilities, skilled surgeons, and inclusive environments where individuals can achieve their desired transformations. Before making a decision, it is essential to conduct thorough research, consult with healthcare professionals, and consider personal preferences and needs. Ultimately, the journey towards aligning one's gender identity with their physical appearance should be met with understanding, compassion, and excellence in medical care.

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For those seeking medical care abroad, we highly recommend hospitals and clinics who have been accredited by Global Healthcare Accreditation (GHA). With a strong emphasis on exceptional patient experience, GHA accredited facilities are attuned to your cultural, linguistic, and individual needs, ensuring you feel understood and cared for. They adhere to the highest standards, putting patient safety and satisfaction at the forefront. Explore the world's top GHA-accredited facilities here . Trust us, your health journey deserves the best.

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Home - Transgender

Transgender – sex reassignment surgery

When a person cannot identify with the gender assigned at birth, that person’s status is referred to as transgender (formerly transsexuality).   Primarily, transgender is not a problem per se, but simply the certainty of feeling you belong to a sex other than the one assigned to you, or to neither, and the wish to be acknowledged in that affiliation both socially and juridically.   There are a number of possible gender identities that come under the umbrella term ‘trans’ or stand alone. Ultimately, each of them is a very individual, alterable identity.   The road to sex reassignment has now been smoothed, though it does still feature some bureaucratic hurdles. Talk to us about it. We’ll help you find your own individual way forward, and we’ll be at your side to advise you.   Given that the medical services at the place where they live are often limited, many transident individuals are prepared to travel long distances, sometimes even going abroad, to adapt their phenotype, though the aftercare in such cases may not necessarily be assured to an appropriate degree. If you have already had surgery, we can offer post-operational care here at the practice and will advise you if there are any complications.   In Germany, the diagnosis of the transgender characteristic is geared to the International Statistical Classification of Diseases and associated health problems (ICD – transsexualism according to ICD F64.0) issued by the World Health Organisation (WHO).   Many transgender and non-binary individuals feel hurt when their gender feeling is classified as a disease or disorder. However, categorisation in ICD-10 and recognition as a disease pursuant to SGB V (Book V of the German Social Security Code) do at least have the advantage for those concerned that the health insurance providers meet the costs for diagnostics and treatment once the diagnosis has been confirmed.   If you are considering applying for the costs of sex reassignment surgery to be borne by your statutory health insurance provider, there are as a rule some conditions that need to be fulfilled. Having said that, we would like to draw your attention to the fact that in our practice clinic we cannot perform any operations with reimbursement for out-patient care services as defined by the statutory health insurance providers (on the so-called standard assessment scale [EBM]). In individual cases, however, you may be able to come to a special agreement with your provider. For direct payers and privately insured patients, (depending on their individual contract profile), these restrictions do not apply.   As a rule, paramount to sex reassignment surgery is the removal of the protruding chest with the aim of adapting to an appearance that corresponds to the patient’s gender perception, or the construction of a protruding chest. A chest that does not fit in with the person’s sexual identity often constitutes the greatest visible stigma for the patient. Which surgical procedures are suitable in your particular case depends on your initial findings.   We can offer you either realignment to a flat chest for trans people assigned female at birth (AFAB), or the creation of a protruding chest for trans people assigned male at birth (AMAB). We can perform all the operations that are necessary to achieve an optimum result for you, so that you can get just that little bit closer to your long awaited goal of uniting your body with the way you feel.   We work together with a network of microsurgeons, gynaecologists, urologists and endocrinologists who will also advise and assist you.   In a detailed consultation, we can talk about the gender reassignment measures which will achieve the result that is best for you.

Ask our advice.

We’ll be glad to provide you with detailed information about this treatment. Simply get in touch with us now and obtain advice at an individual and absolutely personal level. +49 30 - 94 041 144

Wolff & Edusei Practice Clinic

Specialist practice for plastic and aesthetic surgery   Taubenstraße 26 10117 Berlin (Mitte)

• +49 30 - 94 041 144
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WORLD LEADER IN GENDER REASSIGNMENT SURGERY

The most advanced clinic in Europe

Gender reassignment surgery, what is gender reassignment surgery.

Gender reassignment surgery, confirmation surgery or sex reassignment surgery means a variety of procedures that allow people transition to their self-identified gender. These surgical treatments modify a physical person’s appearance and sexual characteristics to approach their identified gender.

The most common treatments are feminization surgeries are vaginoplasty, breast augmentation or facial aesthetic procedures. In the cases FTM, phalloplasty, breast reduction or facial masculinization operations are the most demanded surgeries.

Our gender affirming treatments and procedures

We offer a wide range of gender confirmation procedures to help our patients to achieve the results they are looking for, supporting and providing professional advice throughout the transformation process.

Feminisation surgery

MTF Vaginoplasty

Facial feminization

BREAST AUGMENTATION

MTF body surgery

FEMINIZING VOICE SURGERY

AESTHETIC MEDICINE

Masculinisation surgery.

Phalloplasty

Metoidioplasty

FTM top surgery

FTM Hysterectomy

Body Masculinization

OTHER MASCULINIZATION SURGERIES

Before and after gender-affirming surgery results.

Knowing the results of some sex reassignment surgeries could be helpful to make a decision and to have an idea about what to expect.

Dr. Ivan Mañero, a reference

Dr. Ivan Mañero, reconstructive and aesthetic plastic surgeon, is an international leader in gender affirmation surgery (ies) for trans people. He has been performing and perfecting gender reassignment surgeries for more than two decades, both inside and outside our borders.

His professionalism has led him to be internationally known and sought after, participating and moderating events in conferences. From the beginning of his professional career, he has always advocated for specialized and sensitive care for trans people. However, in the beginning, he had to deal with other peers who did not understand why a specialist like him cared about this matter.

A pioneer in unique surgical techniques for gender reassignment, Dr. Ivan Mañero has collaborated with various administrations to ensure that this type of a surgeries re included within the public health service in Spain. . In order to be able to offer greater and better care to trans people who require it.

The IM GENDER team, led by Dr Ivan Mañero, is a leading international reference in sex reassignment surgery and genital reassignment surgery.

World leader in gender reassignment surgery

The IM GENDER Gender Unit opened its doors over twenty years ago and has become an international benchmark in Gender Reassignment Surgery. IM GENDER has cared for more than 3,000 trans people who have decided to carry out some treatment or surgical procedure at the Unit, whether genital affirmation surgery – vaginoplasty, phalloplasty, metoidioplasty -, body surgery – mastectomy, breast augmentation, feminizing liposculpture, among others -, facial surgery – facial feminization, thyroplasty, masculinization of features, etc.- or other plastic surgery procedures.

IM GENDER offers all the advantages of IM CLINIC, a pioneering clinic for its concept of understanding healthcare in a global and personalized way. Our clinic confers differentiating characteristics that allow us to offer a high quality of care.

At IM GENDER you will find a clear commitment to the most cutting-edge and reliable technology, with technologically cutting-edge operating rooms and the most innovative equipment in the sector. All this, added to a medical team expert in gender surgery with more than two decades of experience led by Dr. Ivan Mañero, the most recognized plastic surgeon specialized in gender reassignment surgery in Europe and even internationally. In addition, Dr. Mañero was a pioneer in unique/specific surgical techniques for genital affirmation, such as vaginoplasty with graft.

The entire human team that makes up IM GENDER, from Patient Care to medical, health professionals, psychologists and physiotherapists, are trained in health care based on human rights, respect and privacy of all patients. Our goal is to offer all the necessary information before, during and after the surgery through close treatment and personalized attention.

YEARS OF EXPERIENCE

Im gender specialists.

THEIR EXPERIENCE COULD BE YOURS

Meet IM GENDER’s true stars and learn about their personal experiences, from preoperative consultations to postoperative follow-up care. Discover how our comprehensive approach to gender-affirming surgery, (ies) coupled with our psychological support and family guidance, has made a difference in their lives.

At IM GENDER, we understand that every patient’s journey is unique, and we are committed to providing personalised care that caters to individual needs. Our testimonials are a testament to our dedication to patient satisfaction, and we are proud to share the stories of our satisfied clients with you.

We invite you to explore our website and learn more about our services, team, and testimonials. Our team is available to answer any questions or concerns you may have and to help you start your journey towards gender affirmation.

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IM GENDER is the Gender Unit at IM CLINIC, one of the most advanced sex reassignment surgery centers Internationally. A new concept of clinic born from our commitment to experience in the field. IM GENDER is a team of highly qualified professionals, who all believe in the same philosophy of exquisite patient care.

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The German Cabinet has approved a plan to make it easier for people to legally change name, gender

German Chancellor Olaf Scholz, right, speaks with German Justice Minister Marco Buschmann during the cabinet meeting of the German government at the chancellery in Berlin, Germany, Wednesday, Aug. 23, 2023. (AP Photo/Markus Schreiber)

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BERLIN (AP) — Germany’s Cabinet on Wednesday approved a plan to make it easier for transgender, intersex and nonbinary people to change their name and gender in official documents, legislation that the justice minister said aims to make life easier for “a small group for which it has great significance.”

The legislation still needs approval by parliament. It is one of several reform plans that Chancellor Olaf Scholz’s coalition of three socially liberal parties has embarked on, and has been criticized by the conservative opposition.

Under the planned “self-determination law,” which has been in the works for over a year , adults would be able to change their first name and legal gender at registry offices without further formalities. They would have to notify the registry office three months before making the change.

The existing “transsexual law,” which dates back four decades, currently requires individuals who want to change gender on official documents to first obtain assessments from two experts “sufficiently familiar with the particular problems of transsexualism” and then a court decision.

Over the years, Germany’s top court has struck down other provisions that required transgender people to get divorced and sterilized, and to undergo gender-transition surgery.

“Imagine that you ... simply want to live your life and you don’t wish anyone anything bad, and then you’re questioned about what your sexual fantasies are, what underwear you wear and similar things,” Justice Minister Marco Buschmann told ZDF television. “Those affected have found this questioning very degrading.”

“Now we simply want to make life a bit easier for a small group for which it has great significance,” he added.

The proposed legislation focuses on individuals’ legal identities. It does not involve any revisions to Germany’s rules for gender-transition surgery.

The new rules allow minors 14 years and older to change their name and legal gender with approval from their parents or guardians; if they don’t agree, teenagers could ask a family court to overrule them.

In the case of children under 14, parents or guardians would have to make registry office applications on their behalf.

Asked about concerns that young people could make premature decisions, Buschmann said he is “firmly convinced that the overwhelming majority of parents will ask themselves very seriously and carefully: what is the best thing for my child?”

After a formal change of name and gender takes effect, no further changes would be allowed for a year.

Under the new legislation, operators of, for example, gyms and changing rooms for women would continue to decide who has access, Buschmann said. He added experiences elsewhere have shown that “as a rule, this is not a practical problem; nonetheless, we have resolved it to address the concerns of those who were concerned about it.”Spain’s parliament in February passed a law that allows people over 16 years of age to change their legally registered gender without any medical supervision.

In the U.K., the Scottish parliament in December passed a bill that would allow people aged 16 or older to change the gender designation on identity documents by self-declaration. That was vetoed by the British government; Scotland’s first minister has vowed to challenge that decision.

Guide for newly immigrated and refugee trans+ people

What can you find out in this guide?

• What transsexual, transgender, trans+ and other terms mean
• That and how you as a trans+ person are protected by law in Germany
• How you can deal with discrimination
• How to change your first name and gender information
• What options are there for adapting your body to your “true” gender
• Where you can find support and help
• Where you can meet other trans* people

The text is a shortened and slightly adapted version of “Trans* Geflüchtete Willkommen – Ein Ratgeber für neu zugewanderte und geflüchtete trans* Menschen”. Our thanks go to the authors Freddie* Heithoff and Mika Schäfer as well as rubicon e.V. and Netzwerk Geschlechtliche Vielfalt Trans* NRW e.V. , which developed the texts and made them available to LSVD.

If you’re looking for detailed information on the asylum procedure, you can find it in the form of a specific guide under Short guide or as explanatory films at Video .

• Trans+ definitions and other important definitions

It’s entirely up to you how you define yourself. It may be that one of the following terms feels appropriate for you, but it doesn’t have to be.

Transsexual/ transident/ transgender

When a child is born, the decision is made on the basis of certain sexual organs (vagina or penis) whether the child should grow up as a girl or a boy. Many trans+ people realise even as children that this doesn’t feel right for them. If a person decides that they no longer want to live in the gender that was attributed to them at birth, there are various ways to live as a member of the other gender. We explain these options in this brochure. People who (want to) live in a different gender than the one they were attributed at birth often define themselves as transsexual, transident or transgender.

Trans+ woman

A person who was defined as a boy at birth, but feels like a woman and now lives as a woman.

A person who was defined as a girl at birth, but feels like a man and now lives as a man.

Non-binary / NB / Enby 

In society, the idea that there are only two genders – man and woman – prevails. In fact, there are many more than two genders. People who don’t clearly or exclusively define themselves as a man or woman are considered non-binary. People who do not clearly or exclusively define themselves as man or woman are considered non-binary. These people may define themselves as “neither nor”, “as well as”, “in between”, “without” or “with any gender”.

Trans+, trans+ person

All people who don’t feel that they belong to the gender that was determined at birth can call themselves trans+. The asterisk (*) or the plus sign (+) in German are placeholders for self-definitions such as transgender, transident, non-binary. They show that there are countless gender identities that can be found in this term. People who feel that they belong to the gender that was documented for them at birth are referred to as “cis”.

We call transition the transition to another gender, for example from man to woman, or the alignment of external characteristics with the felt gender. There are various ways of adapting to another gender. For example, you can choose a new first name that suits you well and tell other people about it. You can also have your first name and your gender entry officially changed: Your passport will show the name and gender that you’re comfortable with. You also have the option of changing your appearance to match your “real” gender. You may want to start a hormone treatment, adjust your body through surgery or wear the respective clothes. In this brochure we explain the different options available and how you can implement them. Which steps someone takes is up to each person to decide for themselves. You don’t have to take hormones or have an operation to be yourself. You decide for yourself what feels good for you!

Most people want to be recognised as the gender in which they feel comfortable. In other words, if you feel like a man (i.e. you are a man), you probably also want other people to see and address you in this way: You want to pass well. Hormone treatment and/or surgery are helpful but not necessary. Wearing the appropriate clothes also has a strong effect on how you pass. You can see if you are satisfied with the way you pass and what steps you want to take to change the way you pass.

There are two types of coming out: coming out to yourself and coming out to others. When you become aware that your gender identity doesn’t match the gender that was established at your birth, this is called “inner coming out”. Coming out to yourself can take a long time and doesn’t happen from one day to the next. If you decide to tell your family, friends, or other people about it, this is called the “external coming out”. There are many people who don’t come out to others, or only tell individual people about it, especially if being trans+ is prohibited in their country, for example. You don’t have to tell anybody about your feelings. But sometimes it helps to open up to certain people, to exchange ideas or to ask for advice.

Pronouns are elements of language that refer to people and give an indication of their gender. In German, for example, these are “er/ihn/ihm” (=he/him) or “sie/sie/ihr” (she/her). If you decide to live openly in the gender you identify with , you probably want other people to address you in this way. So most trans+ women choose the pronoun “she”, trans* men usually choose the pronoun “he”. For people who are neither woman nor man, i.e. who are not binary, there is unfortunately no official pronoun in German. Non-binary people therefore often look for other possibilities and develop their own pronouns for themselves such as “they” or “ze/hir/hirs” (pronounced “zee/here/heres”) or “ey/em/eir” (pronounced “ay/em/airs”), among others, in English or “sier”, “er*sie” or “nin” in German. Some also use their first name as a pronoun. It can be very hurtful for people if someone uses the wrong pronoun for them. We can’t know what gender people define themselves as. That’s why it’s good to ask people which pronoun they prefer.

LGBTIQ+ (LSBT*I*Q in German)

The letters stand for Lesbian, Gay (“Schwul” in German language), Bisexual, Trans+, Inter+ and Queer. These groups of people are often addressed together because there are common movements and offers. But the terms stand for different things: Lesbian, gay and bisexual are sexual orientations (so: Who do I love? Who do I like?). Inter+ people have bodies that do not exclusively correspond to the widespread idea of “female” or “male”. Trans+ people can be heterosexual, lesbian, gay or bisexual. They can also be inter+.

The term queer is often used as a collective term for people who don’t want to fit into a category or who deviate from a social norm. For example, queer can be defined as people who don’t classify themselves as either man or woman, but who don’t find the term trans* appropriate for themselves. People of different sexual orientations can also be found under this term.

Gender identity

Your gender identity means that you feel or identify yourself as a woman, a man or as a non-binary person. Gender identity stands for what’s going on inside you and can develop independently of how you present yourself to the outside world.

Sexual orientation

Sexual orientation describes which sex you find attractive. This can be on a romantic and/or sexual level. Your sexual orientation and your gender identity are independent of each other. So if you decide that you want to live as a man through a transition and have previously loved or desired men, you can still do so as a trans+ man. Or vice versa, if you loved or desired women before, you can still do so after the transition. Whether you’re gay, lesbian, bisexual, heterosexual or otherwise has nothing to do with your gender. Your sexual orientation does not have to change with the transition. It can change. Both are perfectly fine.

Gender roles

Gender roles are shaped by society. This means, for example, that a society expects a boy to play with cars and a girl with dolls. Even though this has already changed in many areas in Germany today, it still often happens that certain interests or characteristics are attributed to one gender. These often have to be fulfilled by the individual in order to be accepted by society. Gender itself – as well as gender roles – is therefore shaped by society. Children first learn that their gender must be exactly the same as that which was determined by doctors at birth. However, people can be different and behave differently than they are expected to. So the fact that a child is born with a penis doesn’t mean that they have to live as a boy, but rather that they can decide in the course of their life whether they want to live as a woman, a man or as a non-binary person and how they express their gender.

Intergender, intersexual, inter+

If a person for instance can’t be clearly classified as a girl or boy at birth because they don’t have the typical sexual characteristics, but are “between the sexes”, we speak of intersexuality. For example, a child can be born with a vagina and testicles that have grown inwards. Some inter+ people don’t notice until puberty that their body doesn’t develop in the same way as that of other children, for example when a girl develops beard growth. People can also be inter+ without ever knowing it. Like all other people, inter* people can experience and define themselves as men, as women or as non-binary. Many inter+ people are often operated on in childhood without their consent in order to create “clearly female” or “clearly male” sexual characteristics. This brochure is not specifically aimed at inter+ people. However, some topics are relevant to you and of course you can also contact the counselling centres if you have any questions (see section 4).

• Discrimination

Discrimination means that a person is treated differently or worse than other people, for example because of the colour of their skin or their gender.

Anti-Discrimination Act

In Germany, as a transsexual/transident person, you’re protected by law against discrimination.

The Basic Law is the constitution of the Federal Republic of Germany and the most important and highest law in Germany. In the Basic Law of the Federal Republic of Germany it says that the state may not discriminate against or prefer anyone because of their gender or origin (Article 3 GG).

In addition, the General Equal Treatment Act (Allgemeines Gleichbehandlungsgesetz/AGG) applies. It prohibits discrimination against people on the following grounds:

• Religion or belief
• Disability or chronic illness
• Origin or skin colour
• Sexual orientation or identity

There are different reasons why people are discriminated against by others. For us, the points “origin and skin colour” and “gender” are particularly important in this brochure. Because the law says that people must be treated equally, regardless of whether they may for example come from Germany, Afghanistan, Bulgaria, China or another country. Likewise, trans+ people must not be treated differently or worse than other people.

The General Equal Treatment Act applies above all in working life and in various areas of everyday life. For example, a Muslim woman may not be turned away at a job interview because she wears a headscarf. It’s also forbidden not to rent an apartment to people because of their origin, or not to serve someone in a restaurant because he or she is trans+.

Here you can read in eight different languages in which areas you’re protected by law:

Federal Anti-Discrimination Agency

Transphobia (Transfeindlichkeit in German)

The term transphobia refers to prejudices, negative attitudes or aggression towards trans+ people.

Although the anti-discrimination law applies in Germany, transphobic discrimination and harassment also occurs in Germany. Unfortunately there are many people in Germany for whom transsexuality/transgender is not “normal”. A study from 2012 shows that 73 % of trans+ men and 85 % of trans+ women have been discriminated against in the last five years.

There are various forms of discrimination that trans+ people have to deal with. These include insults, (repeated) use of the wrong pronoun (misgendering), questions about intimate details, sexual assault and other forms of violence.

The procedures that people have to go through to get approval for hormones or a first name change, for example, can also be very stressful for those affected. These procedures can take a long time and cost money.

Dealing with discrimination / sources of support

You are not alone!

There are plenty of ways to get help!

If you are affected by discrimination, there are different ways to deal with it. You can try to find a way to deal with it for yourself. If something discriminatory is said to you, you can try to ignore it or turn a blind eye. If you know that there are certain places where you aren’t treated well, you can try to avoid them. You can also look for an environment where you feel comfortable and where you’re accepted just the way you are. For some people these are friends or relatives. For others, support groups or other groups for trans* people can be just such an environment. There are people there who have similar experiences to yours and who you can talk to about problems.

In these and other environments you can also find people who can help and support you. There are also counselling centres that you can turn to if you’ve been subjected to violence.

In section 1 we have already briefly explained which steps a transition can involve. Here we’ll describe the possible steps in more detail. However, this doesn’t mean that it always has to go this way. Sometimes procedures take longer or obstacles or problems arise. Unfortunately we can’t explain every possible step of the transition in detail here. Therefore, it’s very advisable to get support to accompany you during your transition. Both a counselling centre, which explains everything in detail, and people who accompany you emotionally on your way can be very helpful.

Legal requirements / first name and civil status changes

In Germany the Transsexual Act (Transsexuellengesetz/TSG) has been in force since 1981. This law gives trans+ people the opportunity to legally adopt the appropriate gender.

This law also applies to you as a refugee if:

• you are a “stateless foreigner” in Germany
• you have your residence in Germany as an asylum seeker or “foreign refugee”, or
• there are no regulations such as the Transsexual Act in your country of origin and you have an unlimited right of residence, or a renewable residence permit and are regularly and permanently resident in Germany.

If you have not yet completed your asylum procedure or have been rejected, you will unfortunately have to wait until you have been granted a residence permit in a (new) procedure. However, you can already start with the first steps during the waiting period (e.g. go to a counselling centre, find a therapist).

The law mainly regulates that and how you can change your first name and/or your civil status (gender entry) in your papers. So that you can do this, you must fulfill the following requirements according to §1 of the Transsexual Act:

• You must have felt you belong to the opposite gender for at least three years and have a strong inner need to live in that gender
• It must be highly probable that your affiliation to the opposite gender will not change. A court will check whether you fulfil these conditions. For this purpose the court commissions two expert opinions. This is criticised by many trans+ people. You can suggest experts to the court. For recommendations on experts, it is best to contact a local group. The experts will talk to you and write an expert opinion with their assessment, which the court will then receive. The court will decide whether your first name and/or civil status may be changed.

You also have the option of changing your first name only and changing your civil status (gender entry) later or not at all. If you want to change both, it is best to request both changes at the same time.

For assistance and more detailed information on the procedures, please contact one of the trans+ counselling centres. Self-help groups can also help you.

It is possible that the Transsexual Act will soon be amended. New regulations should make it easier for trans+ people to change their name and gender entry. For information on current developments, it’s best to contact a counselling centre or a self-help group.

Since the end of 2018, there has been a gender entry “diverse” (“divers” in German) in Germany in addition to the gender entry “male” or “female”. However, this option is not open to all people, but primarily to inter+ people. For the gender entry “diverse” you currently need a certificate from a doctor stating that you have “variants of gender development”. But this could change soon.

Good news: without an expert opinion or similar, you can get what’s referred to as an Ergänzungsausweis (complementary ID) from the Deutsche Gesellschaft für Transidentität und Intersexualität e.V. (dgti). It contains the name, gender and pronoun you have chosen for yourself. This identity card is a support in everyday life, but it is not an official identification document.

The website for this is only in German. For more information on how to get the card and what you can use it for, you can ask at a counselling centre or a self-help group.

Options for reassignment / assumption of costs

The adaptation of your body to your “true” gender and your first name and marital status changes are not interdependent. You can decide for yourself if you want to go all these ways or not. If you only want to do hormone treatment without changing your official gender, that’s perfectly fine. On the other hand, if you want to change your official gender and/or your name, no one can force you to have an operation.

There are different options for undergoing a physical transition:

Trans+ men:

• Hormone treatment (testosterone)
• Breast removal
• Removal of the uterus, ovaries and fallopian tube
• Construction of a penis

Trans+ women:

• Hormone treatment (oestrogen)
• Breast reconstruction
• Removal of the testicles and the penis
• Building a vagina
• Laryngeal reduction
• Surgical voice adaptation
• “Face feminisation”
• Facial hair removal by laser or needles
• Hair transplantation

In addition, trans+ women can change their voice through voice training. Even people who are neither men nor women can request these measures for themselves. They can get them, but often it’s more difficult for them than for trans+ women and trans+ men. It’s best to get advice and support.

Many of these measures are paid for by the health insurance company. If you have a residence permit, you are covered by state health insurance. This means that the same costs are covered for you as for German citizens. If your asylum procedure has not yet been completed or your asylum application has been rejected, you unfortunately only have a limited right to medical care. It is therefore possible that hormone treatment will not be financed. In many cases, however, hormone treatment is approved for people without full insurance cover. If you have problems, you should contact a counselling centre that can help you. Support groups can also help you with a lot of questions (see Section 4).

Hormone treatment

Hormone treatment changes your body. The process is different for every person. Mostly the body shape (fat and muscles), the face shape and the skin change. In addition, trans* men can grow beards and a deeper voice, among other things. Trans+ women often develop some breast growth and their body hair becomes less. It is very important that you consult your doctor about hormone treatment. To get hormones, you need an “indication”, i.e. a diagnosis from a doctor, psychiatrist or psychologist. The requirements for an indication aren’t fixed; sometimes a single appointment can be sufficient. You don’t have to pay for the hormones you get yourself, as they are covered by your health insurance.

Psychotherapy

The costs for psychotherapy in connection with transsexuality/transidentity are covered by the health insurance. Psychotherapy can help you on your way and is a very important basis for a transition. Therapists can also write you the report you need so that gender-reassignment surgeries are paid for by the health insurance company. If you already know that you want this, you should ask the therapist at the beginning of the therapy.

Gender reassignment surgery

Under certain conditions, many of the gender reassignment surgeries we’ve listed above can be covered by health insurance. Unfortunately, operations that are described by the health insurance as “cosmetic” (especially face feminisation, larynx reduction and hair transplantation) are not financed by the health insurance. Whether breast reconstruction is paid depends on how large the breasts have become as a result of hormone treatment.

In order for the health insurance to pay for gender-reassignment surgery, you must meet several requirements: You must have been taking hormones for at least 6 to 12 months, have had psychiatric-psychological support for at least 18 to 24 months and have been living in your “true” sex for 12 to 18 months (“everyday life test”). A therapist writes a detailed statement about this, known as an “indication report”. This document is sent to the health insurance company together with other documents. A competent body, the Medical Service of the Health Insurance Funds (MDK), usually issues an expert opinion on whether the measure should be paid for by the health insurance fund. The health insurance companies then decide on the basis of this appraisal.

It’s essential that you seek assistance from a counselling centre. There you will find important information and support. Self-help groups can also help you with many questions.

• Contact points for trans+ people

Under Organizations you can find a map with all specialised counselling centres and group services for LGBTI+ refugees.

There are many different services for trans+ people: Trans+ counseling centers with professional counselors, voluntary trans+ counselling and trans+ groups. The people there don’t all have detailed knowledge about refuge and asylum, but can help you with a variety of questions about trans identity and trans sexuality, for example: How do I know that I am trans+? How can I get hormones? What kind of operations are there and what do I have to do? What can I do if I am discriminated against? You can also talk about your wishes and fears in peace. And in trans* groups you can meet other trans* people in peace and quiet.

If you can’t or don’t want to be counselled in German, you can bring someone along to interpret for you. If you don’t know who you can bring along, ask at a counselling centre.

Unfortunately the following websites are mainly in German. If you don’t speak German very well yet, you can ask a person you trust to help you with the translation.

On the dgti website you can find nationwide support services that have special expertise in the field of transsexuality and transidentity under Beratungsstellen (counselling centres). The Regenbogenportal also gives a good overview of nationwide services. A list of contact points for trans+ people in North Rhine-Westphalia (counselling centres and groups) can be found on the website of the Netzwerk Geschlechtliche Vielfalt Trans* NRW e.V. .

Other interesting websites, forums and Facebook groups for trans+ people

Hormonmädchen

Gendertreff

Transsexuell.de

TransMann e.V. (for trans+ men)

In these forums you can exchange ideas with other trans+ people and find lots of information.

Gendertreff-Forum

TransTreff-Forum

FTM-Portal (Forum for trans+ men)

NBForum (Forum for non-binary people)  

Facebook groups:

You can also exchange information with other trans+ people in closed Facebook groups.

Transgender Germany – TGG

Deutschsprachige Enby / Non-Binary Menschen (for non-binary trans+ people)

Transgender Support Circle (in English)

All transmen know each other (for trans+ men, in English)

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Healthcare for Trans*gender People in Germany: Gaps, Challenges, and Perspectives

Nora guethlein.

1 Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany

Melina Grahlow

2 Graduate Training Centre of Neuroscience, University of Tübingen, Tübingen, Germany

Carolin A. Lewis

3 Emotion Neuroimaging Lab, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany

4 International Max Planck Research School on Neuroscience of Communication: Function, Structure, and Plasticity, Leipzig, Germany

Stephan Bork

5 Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany

6 Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany

Birgit Derntl

7 LEAD Graduate School and Research Network, University of Tübingen, Tübingen, Germany

8 International Max Planck Research School for Cognitive and Systems Neuroscience, University of Tübingen, Tübingen, Germany

9 TübingenNeuroCampus, University of Tübingen, Tübingen, Germany

Associated Data

The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.

People whose gender does not correspond to the binary gender system, i.e., trans ∗ gender people, face two main problems when it comes to healthcare in Germany: (1) They often suffer from general psychiatric comorbidities as well as specific and significant mental distress due to gender dysphoria, and (2) the German healthcare system lacks sufficiently educated and clinically experienced medical personnel who are able to provide specialized healthcare. Aside from transition, it often is extremely difficult for trans ∗ gender people to get access to and be integrated into the medical system. Stigmatization and pathologization in treatment are widespread, as are long waiting times for specialized healthcare providers who are often only accessible to those trans ∗ gender people willing to travel long distances. Frequently, trans ∗ gender people face further difficulties and barriers after transition, as some healthcare professionals fail to provide suitable care (e.g., gynecological consultation for transmen). The ICD-11 German Modification (ICD-11-GM), which should be routinely used by 2022, implements a depathologization of trans ∗ gender people in the medical system. This paper compares the issues related to health and healthcare of trans ∗ gender people in Germany with those in other European countries. We review the care offered by specialized centers with regard to treatment of and support for trans ∗ gender people. We conclude with specific proposals that may contribute to establish an improved, up-to-date, gender-sensitive healthcare system.

Introduction – Gaps and Challenges

Modern societies are widely dominated by a hegemonic binary view of people’s gender identity as well as a heteronormative understanding of relationships. Even in liberal democracies, where a pluralist understanding of different sexual, religious and lifestyle orientations are commonly accepted, trans ∗ gender people are confronted with this “heterosexual matrix” ( Butler, 1991 ) on a daily basis. Correspondingly, the healthcare systems in these societies have institutionalized an exclusive binarity: medicine largely operates with the classification “male” and “female” as the only expected expression of gender, with most of the current models for mental disorders still relying on male data only ( Shansky, 2019 ). This is especially problematic when it comes to healthcare for non-binary people. They face insufficient medical care, which is aggravated by treatment providers’ lack of awareness of their concerns and insufficient knowledge of gender-sensitive medicine. People whose gender identity does not correspond to the perceived norm are negatively affected by this lack of knowledge with some of them facing severe stress and discomfort. Unsurprisingly, trans ∗ gender individuals are at higher risk to report mental health problems than cisgender individuals. For example, a recent comparative study of mental health issues among cisgender and trans ∗ gender people indicated that 77% of the included trans ∗ gender participants were diagnosed with a mental disorder vs. 37,8% in cisgender participants ( Hanna et al., 2019 ). Several studies show an elevated risk for affective disorders, anxiety disorders, and addictive disorders in trans ∗ gender people compared to cisgender individuals ( Reisner et al., 2016 ; Bouman et al., 2017 ; De Freitas et al., 2020 ). In addition, increased suicidality for trans ∗ gender people compared to the cisgender population has been reported ( Goldblum et al., 2012 ; Bailey et al., 2014 ; Reisner et al., 2016 ; Adams et al., 2017 ; Yüksel et al., 2017 ). This increased risk of comorbidities could be replicated in several countries worldwide, including data from the Lebanon ( Ibrahim et al., 2016 ), the United States ( Hanna et al., 2019 ), and the Republic of Côte d’Ivoire ( Scheim et al., 2019 ). Consequently, mental health issues do not result from gender incongruence and stress/rejection/discomfort experienced by the individuals alone but are possibly further promoted by the binary-gendered thinking and treatment routines of the healthcare systems as they exist in most societies around the globe.

Interestingly, the question why trans ∗ gender people have increased comorbidity rates can still be considered unanswered ( Reisner et al., 2016 ). Some authors refer to the model of internalized homonegativity in order to explain increased risk and high prevalence of mental comorbidities in trans ∗ gender people ( Bockting et al., 2013 , Bockting, 2015 ; Breslow et al., 2015 ). Internalized homonegativity describes how non-heterosexual people internalize socio-culturally predetermined negative attitudes and images ( Göth and Kohn, 2014 ). This model is in line with societies’ heteronormativity as it explains how predominant socio-culturally norms can lead to self-pathologizing ( Rauchfleisch et al., 2002 ; Günther et al., 2019 ) which in turn can cause psychological distress and may finally result in mental health conditions ( Bockting et al., 2013 ; Breslow et al., 2015 ; Perez-Brumer et al., 2015 ; Scandurra et al., 2018 ). This internalization process can be applied correspondingly to trans ∗ gender persons inasmuch as gender identities are conceived of as stable, binary and invariant personality traits. Accordingly, this can be conceptualized as internalized transphobia ( Bockting et al., 2013 ; Bockting, 2015 ; Breslow et al., 2015 ). The notion that mental comorbidities solely arise due to gender incongruence and dysphoria therefore seems decidedly too one-dimensional, ignoring the underlying complexity.

The Evolution and Current Healthcare for Trans ∗ gender in Germany

Trans ∗ gender healthcare in Germany has a centennial history already. In 1922, the German sexologist Magnus Hirschfeld, founder of the first Institute for Sexology, carried out the worldwide first sex reassignment surgery in Berlin ( Bhinder and Upadhyaya, 2021 ). In the post-war German society, the situation of trans ∗ gender persons was recognized only very haltingly. The so-called “transsexual law” (TSG) from 1980 implemented changes of personal and civil status. The law since required trans ∗ gender persons to undergo surgical alteration of their genitals in order to have key identity documents changed. This was declared unconstitutional only in 2011.

Besides the legal framework there were no regulations for medical and psychotherapeutic healthcare for trans ∗ gender people whatsoever until the publication of the German Standards for the Treatment and Diagnostic Assessment of Transsexuals (1997) ( Nieder and Strauß, 2015 ). These standards provided temporal and diagnostic frameworks and concrete guidelines according to which gender-affirming procedures may take place. Stemming from the desire to enable trans ∗ gender people to follow a self-determined and individualized transition, the new S3 guidelines from 2018 [“Gender incongruence, gender dysphoria, and trans health: S3 guideline on diagnosis, counseling, and treatment” ( Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [AWMF], 2019 )] have been developed in collaboration with experts and interest groups. In contrast to the precursor from 1997, the new guidelines take a less directive and more participatory approach ( Nieder and Strauß, 2019 ). Hence, treatment seekers and treatment providers are now able to find individual solutions together on equal terms. Access restrictions should no longer exist. Thus, gender-affirming hormone treatment can already be used after diagnosis, at the beginning of the transition. Psychotherapy should no longer be a prerequisite for gender-affirming therapy but should accompany the transition and promote self-acceptance and stability ( Nieder and Strauß, 2019 ). However, the report guidelines of the medical service of the health insurance funds (MDS) contradict the S3 guidelines by continuing to set strict framework conditions for the treatment costs to be covered by the public health insurance funds. Also, the guidelines for the diagnosis of trans ∗ gender criteria from the ICD-10 catalog are less flexible and more stigmatizing than the S3 guidelines. Trans ∗ gender is coded as “transsexualism” ( Graubner, 2013 ). There, the main criterion is the desire of a person to belong to the binary opposite gender. This may include the desire to change sex characteristics (primary or secondary) and to be recognized as belonging to this gender. The desire must be constant for 2 years and must not result from mental disorder. The ICD-10 defines transsexualism as a disorder, subclassified in the section of disorders of adult personality and behavior ( Graubner, 2013 ).

Therefore, practitioners in Germany find themselves in a field of tension between the prevailing strict conditions imposed by health insurance and the ICD-10 catalog and attempts to loosen the regulations in accordance with the individual needs of trans ∗ gender people. This also explains ambivalent reactions and uncertainties on the part of the practitioners to the S3 guidelines ( Nieder and Strauß, 2019 ). In this constellation, it is expected that the new ICD-11 catalog 2022 will bring further change, as transsexualism will be coded in the section “Conditions affecting sexual health,” thus separating trans ∗ gender from somatic or mental illness ( Jakob, 2018 ). This was already successfully implemented in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), according to which it is only possible to speak of a disorder when there is relevant suffering due to the gender incongruence (dysphoria) ( American Psychiatric Association, 2013 ). According to MDS the assessment instructions will have to be revised after ICD-11 has been established.

Trans ∗ gender healthcare in Germany is provided in different institutions. Usually, medical services are provided in private practices. In addition, interdisciplinary healthcare supplies are available via outpatient care, such as the regional “Qualitätszirkel.” These are regional associations of multidisciplinary trans ∗ gender healthcare specialists. There are hardly any centers that offer multiprofessional treatment. The interdisciplinary care center at the University Hospital of Hamburg plays a pioneering role in this area. Some university hospitals offer specialized consultation hours, such as the specialized outpatient clinic for transsexuality and trans ∗ gender in Tübingen, which was established in October 2020. This service is primarily aimed at trans ∗ gender people before and during transition. To the best of our knowledge, there are no central registers for medical services for trans ∗ gender people. Online, there are lists of addresses maintained by interest groups. Figure 1 depicts the institutions providing treatment in Germany and the “Qualitätszirkel” (individual practices or clinics that only cover somatic needs are not listed). They offer various services: psychotherapeutic support, indication letters, medical reports to the TSG and partly interdisciplinary services. Healthcare services offered to trans ∗ gender persons are covered by the health insurance and thus are covered publically, as was decided in 1987 by the Federal Social Court, the Bundessozialgericht (BSG 3 RK 15/86). However, letters of indication from experts are necessary in order that services (e.g., hormonal treatment, surgery) are covered by the health insurance.

Institutions providing specialized trans ∗ gender healthcare in Germany. The map shows the location of clinics and regional associations of multidisciplinary healthcare specialists (“Qualitätszirkel”) that offer specialized trans ∗ gender healthcare in Germany, without claiming to be exhaustive. ∗ : According to the clinic‘s website only expert opinions are issued. However, this is listed differently on the website of https://transmann.de . © Bundesamt für Kartographie und Geodäsie.

How Does the Healthcare System Understand Trans ∗ gender Nowadays?

Trans ∗ gender people experience incongruence between the sex assigned at birth and their gender identity. Sex assignment is based on the external genital, which are usually defined in medical literature as indicators of the so-called biological sex. To avoid classifying non-binary gender identities as a deviation from the biological sex, the terminology “assigned gender” or “assignment gender” seems more suitable than the term “biological sex” ( Günther et al., 2019 ). Gender identity describes a person’s certainty and conviction to belong to a certain gender ( Eckloff, 2012 ). This develops during the course of a person’s life and is shaped by biological and social conditions equally ( Göth and Kohn, 2014 ). In trans ∗ gender people, gender identity does not develop in accordance with the assigned sex; the result can be a binary or a non-binary form of gender identity: Binary trans ∗ gender indicates that individuals experience themselves as belonging to the binary opposite gender (i.e., transman or transwoman). However, there are also people who feel they belong to neither the female nor the male gender and/or experience their gender on a continuum between the sexes ( Günther et al., 2019 ).

In terms of prevalence rates in European countries, similar rates have been reported, always indicating a slightly higher prevalence rate for trans ∗ women. The prevalence of the ICD-10 diagnosis of transsexualism is estimated at 1:12000 for trans ∗ women and 1:30000 for trans ∗ men in Germany ( Schneider et al., 2007 ). In Belgium, 1:12900 trans ∗ women have undergone gender-affirming surgery, while in men this ratio is approximately 1:33800 in trans ∗ men ( De Cuypere et al., 2007 ). Netherlands show similar prevalence rates (1:11900 for trans ∗ women and 1:30400 for trans ∗ men) ( Bakker et al., 1993 ). However, an increase in prevalence has been reported in several countries: in Germany, for example, a 2.6-fold increase in the number of inpatients who were diagnosed with a gender identity disorder between 2000 and 2014 has been reported (data of the German Federal Statistical Office) ( Brunner et al., 2017 ). Brunner et al. (2017) discuss the increased amount of informational martials and the facilitated access to gender-affirming therapy as a cause of the reported increase in prevalence. Whether and how destigmatization of trans ∗ gender individuals further contributes to the increased prevalence rates needs to be investigated. Unfortunately, standardized prevalence rates of trans ∗ gender individuals are rarely to be found ( Collin et al., 2016 ), as different definitions of trans ∗ gender samples lead to different results in prevalence, obscuring the systematic investigation. Furthermore, the prevalence might be underestimated, as not all trans ∗ gender persons seek gender affirming therapy ( De Freitas et al., 2020 ). After the introduction of the new ICD-11, it should be possible to record comparable prevalence rates of the diagnosis gender dysphoria instead of transsexualism.

The Healthcare System’s Influence on the Emergence and Maintenance of Suffering of Trans ∗ gender People Focused on the Situation in Germany

The German medical system has institutionalized stigmatization of non-binary people, which has to be especially considered a substantial factor of trans ∗ gender persons’ healthcare situation. This mainly applies to non-trans ∗ gender specific medical care, but also partly to trans ∗ gender healthcare. The variety of experiences of discrimination within the healthcare system have already been pointed out ( Franzen and Sauer, 2010 ; Grant et al., 2011 ; LesMigras, 2012 ; Bradford et al., 2013 ; Roberts and Fantz, 2014 ; Günther et al., 2019 ). However, since discrimination refers to distinctions that lead to, produce, or give rise to disadvantage ( Scherr et al., 2017 ), it often seems more appropriate to speak of stigmatization in the context of trans-specific healthcare in Germany. Stigmatization means the designation and marking of a deviation from a norm which is given or desired within a society ( Goffman, 1963 ). Stigmatized persons are denied the status of a normal member of society because of an attribution of characteristics marked as a deviation. Institutional stigmatization occurs within social systems or organizations, where routines in communication and actions perpetuate “normality,” which force the presentation and treatment of deviations from this norm as explicit deviations. Trans ∗ gender people experience this institutional stigmatization in modern medicine in Germany and worldwide ( Franzen and Sauer, 2010 ; Fuchs et al., 2012 ; LesMigras, 2012 ).

In itself, the structure of the healthcare system in Germany can be experienced as exclusionary by trans ∗ gender individuals: Identification documents, such as health insurance cards, may not match the gender, cause confusion in providers and can lead to misgendering which in turn is experienced as stigmatizing ( Roberts and Fantz, 2014 ). In the context of medical treatment in Germany, they presumably experience not so much discriminatory disadvantage as invalidation of their gender identity. Günther et al., suggest that exposition to the healthcare system may trigger internalized transphobia among trans ∗ gender people, due to the fact that it occasionally puts the trans ∗ gender individual under pressure to legitimize their own gender identity ( Günther et al., 2019 ).

Because of experienced and/or feared stigmatization, some people are not willing to utilize the medical system. Studies from different countries show that the use of the healthcare system in trans ∗ gender people is reduced due to fear of discrimination ( Bauer et al., 2014 ). In the US-American “national transgender survey” stigmatization experiences of trans ∗ gender persons were documented. One of the key findings reports a high likelihood of discrimination if the medical provider knows about their patients trans ∗ gender identity. They also identify a lack of knowledge by the medical providers, so most of trans ∗ gender people themselves have to inform their doctors about trans ∗ gender healthcare ( Grant et al., 2011 ). In Germany trans ∗ gender persons report that their experiences with the healthcare system depend on whether their trans ∗ identity remains hidden or becomes visible ( LesMigras, 2012 ). Stigmatizing experiences in the healthcare system are among the most common negative experiences of trans ∗ gender persons in Germany, after discrimination at the workplace ( LesMigras, 2012 ). As a result, the health of this group of people is under-supplied, as they typically leave the health system after negative experiences and seek help elsewhere ( Mizock and Lewis, 2008 ).

Due to the deeply embedded heteronormativity in Germany’s society, it is unsurprising that medical areas that are not primarily oriented toward trans ∗ gender healthcare show an unprofessional handling when they face gender identities that do not correspond to this supposed norm. Correspondingly, a study in North-Rhine-Westphalia (Germany) shows that trans ∗ gender persons were hardly satisfied with their psychotherapeutic support ( Fuchs et al., 2012 ). The same study reveals the administrative and treatment burdens caused by the MDS review procedure. It has also been shown, that the institutional pathologizing of trans ∗ identity is experienced as a tremendous burden by trans ∗ gender people ( LesMigras, 2012 ). As outlined in section “The Evolution and Current Healthcare for Trans ∗ gender in Germany,” the German healthcare system has been developing new ways of dealing with trans ∗ gender healthcare. It is in a transition period between strict regulation and self-determination of the trans ∗ gender community. Studies on the fears and wishes of the trans ∗ gender community for multiprofessional treatment centers (as the one in Hamburg) show that also on the part of the treatment providers this development is being worked on and the offers are being adapted to the needs of the trans ∗ gender community ( Eysell et al., 2017 ).

Trans ∗ gender people depend on the healthcare system as they require medical professionals before, during and after gender affirming therapy. Even after a successful transition, psychotherapeutic and somatic care must be ensured. Due to hormone therapy, trans ∗ gender persons have a different lifetime risk profile for cardiovascular diseases ( Aranda et al., 2019 ; Dutra et al., 2019 ; Pyra et al., 2020 ). The risk for sex-hormone dependent cancers is not higher during gender-affirming hormone therapy, but the cancer screening recommendations have to be considered in trans ∗ gender people as well, i.e., prostate cancer screening in transwomen or breast and cervical cancer screening in transmen ( McFarlane et al., 2018 ). Because of this need, it is alarming that the stigmatization in the healthcare system increases the chance for trans ∗ gender people to avoid medical care and balk preventive measures, such as cancer screenings ( Günther et al., 2019 ; Weyers et al., 2021 ).

In addition, studies show that after gender-affirming therapy, psychological stress can also occur, which may lead to increased suicidality ( Rolle et al., 2015 ; Wiepjes et al., 2020 ). The lifetime prevalence of suicidality is also affected – amongst other variables – by negative experience with medical providers ( Haas et al., 2014 ).

Psychotherapeutic services should also strive to offer gender-sensitive counseling in order to adequately address internalized transphobia, specific role conflicts, and so forth. The need for specialized counseling usually is not met after transition, as trans ∗ gender persons are constantly confronted with their minority status in a binary, heterosexual environment ( Verbeek et al., 2020 ). Unfortunately, specialized training programs for psychotherapists are hardly established. Since medical professionals are usually not trained in gender-sensitive medicine and may be out of their depth with regard to the healthcare of trans ∗ gender persons, this ongoing stigmatization comes as no surprise. Therefore, gender sensitive medicine must become a part of the medical curriculum. There seems to be an interest on the part of medical students ( Turner et al., 2014 ). Finally, gender sensitive medicine has to be implemented in the standard medical care in Germany ( Chase et al., 2014 ).

Medical Care Services and Barriers for Trans ∗ gender Individuals in Europe

As we propose, the institutionally co-generated psychological strain on trans ∗ gender persons, promotes comorbidities and further increases economic costs. It seems imperative that stigma-free and need-oriented trans-specific treatment is provided by trained personnel. Only then can we reasonably expect that the psychological distress due to gender dysphoria can be minimized and fused conflicts can be addressed e.g., via psychotherapy. There is evidence for a reduction of distress through access to gender-affirming therapy ( Bränström and Pachankis, 2020 ; Almazan and Keuroghlian, 2021 ).

The mission statement of the European Professional Association for Transgender Health (EPATH), a sub-organization of the World Professional Association for Transgender Health (WPATH), envisions the establishment of uniform European healthcare for trans ∗ gender persons. By drafting a “standard of care” position paper, EPATH tries to formulate a uniform guideline for trans ∗ gender sensitive health care beyond transition. The guideline furthermore establishes basic principles, addressing medical professionals. There is a consensus that healthcare providers worldwide should adhere to these basic principles, regardless of socio-cultural norms and legal requirements of their respective country. Inter alia , EPATH urges medical personnel to treat trans ∗ gender persons respectfully and in a non-pathologizing manner. Access to treatment options should be ensured and medical personnel should be further trained in gender-sensitive medicine ( Coleman et al., 2012 ).

However, uniform and comprehensive care for trans ∗ gender persons is far from guaranteed in Europe, as the legal and medical situation is highly diverse: While some countries have been trying to ensure appropriate treatment of trans ∗ gender persons in the legal and medical domain, trans ∗ gender people in other countries are faced with persecution and discrimination ( ILGA Europe Annual Review, 2021d ). Apart from that, a legal and medical situation that considers the needs of trans ∗ gender people does not necessarily imply that sufficient medical care is provided or that medical staff are sufficiently informed. While there are specialized treatment centers in many European countries nowadays, trans ∗ gender individuals generally face the problem of long waiting times due to the structural lack of healthcare providers in the area of gender-affirming treatment services. In Netherlands treatment options (i.e., diagnostic classification, subsequent gender-affirming therapy such as hormone therapy, gender-affirming surgery) are offered in health centers (Amsterdam UMC, Groningen UMC and Radboud UMC Nijmegen). Like the center in Hamburg, they provide an interdisciplinary treatment – the so-called “gender team.” However, these centers are far from meeting the demand and a lack of healthcare providers in Netherlands has been pointed out recently ( Verbeek et al., 2020 ). In Belgium, care is also provided in healthcare centers (Belgien Universitär ziekenhuis Ghent, Université libre de Bruxelles and Le centre hospitalier universitaire de Liège), with the center in Ghent offering interdisciplinary care ( Elaut, 2014 ). In contrast to Germany, hormonal treatment in Belgium is already possible during full-time real-life experience ( Steinmetzer and Groß, 2008 ). Here, too, the long waiting times have been pointed out as problematic and as an obstacle to the access of appropriate services ( Motmans et al., 2010 ). Specialized care centers in England, Scotland, and Northern Ireland are listed by Vincent (2018) . He points out that trans ∗ gender persons have the longest waiting times of all patients in need of specialized treatment services. In Spain, the healthcare is installed in multidisciplinary gender units in different communities all over the country and the Canary Islands ( Gómez-Gil et al., 2019 ). New healthcare models deviate from the central multidisciplinary gender units, for example by offering gender-affirming healthcare without psychological assessment. These new healthcare models are the subject of controversy, because the decentralization can be considered a missed opportunity: (a) for research and (b) to collected data to evaluate the quality of healthcare ( Gómez-Gil et al., 2020a , b ).

The procedure for gender-affirming surgery in Denmark is prescribed by the Danish Health Authority and is centralized in three clinics (e.g., The Sexological Clinic, Ringshospitalet Copenhagen) ( ILGA Europe Annual Review, 2021c ). Italy is a positive example of a publicly accessible database of medical care professionals. On the website https://www.infotrans.it/ , published in 2020, trans ∗ gender people can find out about treatment services ( ILGA Europe Annual Review, 2021b ).

The situation in Poland stands out as a negative example in a discrepancy to the, as not sufficiently marked, but existing care situation in most European countries. There, no medical care for trans ∗ gender persons is guaranteed. In addition, there is talk of a hate campain against the LGBTIQ community ( ILGA Europe Annual Review, 2021a ).

Overall, healthcare in Europe is taking important steps toward depathologization, and many countries are attempting to establish the requirements of WPATH/EPATH. Worldwide, however, conditions remain poor and self-determination rights are denied to the trans ∗ gender community. In some countries trans ∗ gender persons are still criminalized (e.g., Indonesia, Niger, Malaysia, United Arab Emirates).

Key Findings

The article reviews the medical care situation for trans ∗ gender people nowadays and it provides a more detailed description of the situation in Germany. Three main deficiencies were identified, that are linked to medical care for trans ∗ gender persons in the German healthcare system: (1) A lack of specialized medical care to support transition. Mental comorbidities could be reduced by individualized support during transition. However, this is usually hindered by significant organizational and institutional barriers. Deficits in the structure of specialized healthcare services in Germany and Europe have been pointed out. There is a lack of specialized care offers that ensure a safe place for good care and that alleviate individual suffering through a professionally accompanied transition. (2) A lack of gender-sensitive psychotherapeutic support before and after transition, which could address the trans ∗ gender specific dysfunctional internalization processes in a patient-oriented, professional manner. (3) A lack of sensitivity to special treatment needs in post-transition healthcare. We elaborated that even after transition, a non-discriminatory integration into the healthcare system remains necessary. Due to exclusively binary gender thinking, medicine is prone to institutional stigmatization. Accordingly, trans ∗ gender people are frequently confronted with deficits and hurdles with the safeguard of their health. The multifactorial condition of suffering is modeled in Figure 2 .

Multifactorial condition of suffering. © Bundesamt für Kartographie und Geodäsie.

Perspective

We see an urgent need for the establishment of comprehensive gender-affirmative healthcare. We propose three starting points: (1) A nationwide structure of specialized treatment centers for trans ∗ gender healthcare is needed. In particular, the problem of unacceptably long waiting times must be addressed. (2) Specific sexual medicine training at an early stage (i.e., at university level during education and later on in specialist training) should lay the groundwork to minimize the institutional stigmatization of trans ∗ gender individuals. (3) Finally, we call for the establishment of psychotherapeutic specialization as well as further education programs to support appropriate treatment of the diverse and multifactorial psychological issues of trans ∗ gender people.

It should be pointed out, that through increased cooperation between medical providers and advocacy groups (e.g., Transgender Europe, TGEU), the European healthcare system can be transformed into a system based on self-determination and informed consent. It is time to face and address the many faceted barriers trans ∗ gender people are facing when confronted with the healthcare system in different European countries (and probably world-wide).

In Germany we see a significant progression within the medical system toward the recognition of the trans ∗ gender community and its needs in the recent years. The implementation of the new S3 guidelines is becoming more and more important and the trans ∗ gender community is becoming more and more involved. Unfortunately, this development has not yet reached all areas. The new ICD catalog in 2022 will be an important step to further improving healthcare of trans ∗ gender individuals. We hope to contribute to establishing improved, gender-sensitive medical care in line with the variable demands of trans ∗ gender people.

Data Availability Statement

Author contributions.

NG prepared the first draft of the manuscript. All authors contributed to critically revising and editing the content of the manuscript and approved the final version of the manuscript for submission.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We thank Janina Richter, Tobias Schwippel, and Rebecca Popp for their valuable input. Also, a special thanks to Philipp Rhein, who helped reviewing the topic from a sociological perspective.

MG, CL, UH, and BD were supported by the German Research Association (DFG, DE2319/2-4).

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Access to sex reassignment surgery

Key aspects.

• In thirteen out of twenty-eight Member States, general surgery rules apply as regards the age at which children can request a sex reassignment surgery. In this context, the age requirement for access to medical treatment without the consent of the parents or of a public authority is 18 years in Bulgaria, Cyprus, Greece, France, Hungary, Romania  and Slovakia , and 15 years in Slovenia . In the United Kingdom  the age requirement ranges from 16 in Scotland to 17 in England and 18 in Wales . In Belgium, Estonia, Germany  and Luxembourg  the child’s maturity is assessed.
• In Austria , Czechia, Croatia, Denmark, Finland, Italy, Latvia, Lithuania , the Netherlands , Poland, Portugal, Spain and Sweden the minimum age requirement to request sex reassignment surgery is explicitly set at the age of 18.
• Overall, twenty Member States (and Wales ) only allow sex reassignment surgeries in individuals over the age of 18. Out of these, twelve Member States also set 18 as the age requirement for transgender hormone therapy, while in the case of sex reassignment surgery, eight countries ( Czechia, Denmark, Finland , the Netherlands, Latvia, Poland, Spain and Sweden ) ask for a higher age than for transgender hormone therapy.
• In Ireland and Malta , the age requirement for sex reassignment surgery is 16 years.
• Croatia allows children to have sex reassignment surgery before the age of 18 if they have parental consent, without laying down any specific minimum age requirement.

Language English

PERSPECTIVE article

Healthcare for trans*gender people in germany: gaps, challenges, and perspectives.

• 1 Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
• 2 Graduate Training Centre of Neuroscience, University of Tübingen, Tübingen, Germany
• 3 Emotion Neuroimaging Lab, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
• 4 International Max Planck Research School on Neuroscience of Communication: Function, Structure, and Plasticity, Leipzig, Germany
• 5 Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
• 6 Institute of Neuroscience and Medicine, JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany
• 7 LEAD Graduate School and Research Network, University of Tübingen, Tübingen, Germany
• 8 International Max Planck Research School for Cognitive and Systems Neuroscience, University of Tübingen, Tübingen, Germany
• 9 TübingenNeuroCampus, University of Tübingen, Tübingen, Germany

People whose gender does not correspond to the binary gender system, i.e., trans ∗ gender people, face two main problems when it comes to healthcare in Germany: (1) They often suffer from general psychiatric comorbidities as well as specific and significant mental distress due to gender dysphoria, and (2) the German healthcare system lacks sufficiently educated and clinically experienced medical personnel who are able to provide specialized healthcare. Aside from transition, it often is extremely difficult for trans ∗ gender people to get access to and be integrated into the medical system. Stigmatization and pathologization in treatment are widespread, as are long waiting times for specialized healthcare providers who are often only accessible to those trans ∗ gender people willing to travel long distances. Frequently, trans ∗ gender people face further difficulties and barriers after transition, as some healthcare professionals fail to provide suitable care (e.g., gynecological consultation for transmen). The ICD-11 German Modification (ICD-11-GM), which should be routinely used by 2022, implements a depathologization of trans ∗ gender people in the medical system. This paper compares the issues related to health and healthcare of trans ∗ gender people in Germany with those in other European countries. We review the care offered by specialized centers with regard to treatment of and support for trans ∗ gender people. We conclude with specific proposals that may contribute to establish an improved, up-to-date, gender-sensitive healthcare system.

Introduction – Gaps and Challenges

Modern societies are widely dominated by a hegemonic binary view of people’s gender identity as well as a heteronormative understanding of relationships. Even in liberal democracies, where a pluralist understanding of different sexual, religious and lifestyle orientations are commonly accepted, trans ∗ gender people are confronted with this “heterosexual matrix” ( Butler, 1991 ) on a daily basis. Correspondingly, the healthcare systems in these societies have institutionalized an exclusive binarity: medicine largely operates with the classification “male” and “female” as the only expected expression of gender, with most of the current models for mental disorders still relying on male data only ( Shansky, 2019 ). This is especially problematic when it comes to healthcare for non-binary people. They face insufficient medical care, which is aggravated by treatment providers’ lack of awareness of their concerns and insufficient knowledge of gender-sensitive medicine. People whose gender identity does not correspond to the perceived norm are negatively affected by this lack of knowledge with some of them facing severe stress and discomfort. Unsurprisingly, trans ∗ gender individuals are at higher risk to report mental health problems than cisgender individuals. For example, a recent comparative study of mental health issues among cisgender and trans ∗ gender people indicated that 77% of the included trans ∗ gender participants were diagnosed with a mental disorder vs. 37,8% in cisgender participants ( Hanna et al., 2019 ). Several studies show an elevated risk for affective disorders, anxiety disorders, and addictive disorders in trans ∗ gender people compared to cisgender individuals ( Reisner et al., 2016 ; Bouman et al., 2017 ; De Freitas et al., 2020 ). In addition, increased suicidality for trans ∗ gender people compared to the cisgender population has been reported ( Goldblum et al., 2012 ; Bailey et al., 2014 ; Reisner et al., 2016 ; Adams et al., 2017 ; Yüksel et al., 2017 ). This increased risk of comorbidities could be replicated in several countries worldwide, including data from the Lebanon ( Ibrahim et al., 2016 ), the United States ( Hanna et al., 2019 ), and the Republic of Côte d’Ivoire ( Scheim et al., 2019 ). Consequently, mental health issues do not result from gender incongruence and stress/rejection/discomfort experienced by the individuals alone but are possibly further promoted by the binary-gendered thinking and treatment routines of the healthcare systems as they exist in most societies around the globe.

Interestingly, the question why trans ∗ gender people have increased comorbidity rates can still be considered unanswered ( Reisner et al., 2016 ). Some authors refer to the model of internalized homonegativity in order to explain increased risk and high prevalence of mental comorbidities in trans ∗ gender people ( Bockting et al., 2013 , Bockting, 2015 ; Breslow et al., 2015 ). Internalized homonegativity describes how non-heterosexual people internalize socio-culturally predetermined negative attitudes and images ( Göth and Kohn, 2014 ). This model is in line with societies’ heteronormativity as it explains how predominant socio-culturally norms can lead to self-pathologizing ( Rauchfleisch et al., 2002 ; Günther et al., 2019 ) which in turn can cause psychological distress and may finally result in mental health conditions ( Bockting et al., 2013 ; Breslow et al., 2015 ; Perez-Brumer et al., 2015 ; Scandurra et al., 2018 ). This internalization process can be applied correspondingly to trans ∗ gender persons inasmuch as gender identities are conceived of as stable, binary and invariant personality traits. Accordingly, this can be conceptualized as internalized transphobia ( Bockting et al., 2013 ; Bockting, 2015 ; Breslow et al., 2015 ). The notion that mental comorbidities solely arise due to gender incongruence and dysphoria therefore seems decidedly too one-dimensional, ignoring the underlying complexity.

The Evolution and Current Healthcare for Trans ∗ gender in Germany

Trans ∗ gender healthcare in Germany has a centennial history already. In 1922, the German sexologist Magnus Hirschfeld, founder of the first Institute for Sexology, carried out the worldwide first sex reassignment surgery in Berlin ( Bhinder and Upadhyaya, 2021 ). In the post-war German society, the situation of trans ∗ gender persons was recognized only very haltingly. The so-called “transsexual law” (TSG) from 1980 implemented changes of personal and civil status. The law since required trans ∗ gender persons to undergo surgical alteration of their genitals in order to have key identity documents changed. This was declared unconstitutional only in 2011.

Besides the legal framework there were no regulations for medical and psychotherapeutic healthcare for trans ∗ gender people whatsoever until the publication of the German Standards for the Treatment and Diagnostic Assessment of Transsexuals (1997) ( Nieder and Strauß, 2015 ). These standards provided temporal and diagnostic frameworks and concrete guidelines according to which gender-affirming procedures may take place. Stemming from the desire to enable trans ∗ gender people to follow a self-determined and individualized transition, the new S3 guidelines from 2018 [“Gender incongruence, gender dysphoria, and trans health: S3 guideline on diagnosis, counseling, and treatment” ( Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [AWMF], 2019 )] have been developed in collaboration with experts and interest groups. In contrast to the precursor from 1997, the new guidelines take a less directive and more participatory approach ( Nieder and Strauß, 2019 ). Hence, treatment seekers and treatment providers are now able to find individual solutions together on equal terms. Access restrictions should no longer exist. Thus, gender-affirming hormone treatment can already be used after diagnosis, at the beginning of the transition. Psychotherapy should no longer be a prerequisite for gender-affirming therapy but should accompany the transition and promote self-acceptance and stability ( Nieder and Strauß, 2019 ). However, the report guidelines of the medical service of the health insurance funds (MDS) contradict the S3 guidelines by continuing to set strict framework conditions for the treatment costs to be covered by the public health insurance funds. Also, the guidelines for the diagnosis of trans ∗ gender criteria from the ICD-10 catalog are less flexible and more stigmatizing than the S3 guidelines. Trans ∗ gender is coded as “transsexualism” ( Graubner, 2013 ). There, the main criterion is the desire of a person to belong to the binary opposite gender. This may include the desire to change sex characteristics (primary or secondary) and to be recognized as belonging to this gender. The desire must be constant for 2 years and must not result from mental disorder. The ICD-10 defines transsexualism as a disorder, subclassified in the section of disorders of adult personality and behavior ( Graubner, 2013 ).

Therefore, practitioners in Germany find themselves in a field of tension between the prevailing strict conditions imposed by health insurance and the ICD-10 catalog and attempts to loosen the regulations in accordance with the individual needs of trans ∗ gender people. This also explains ambivalent reactions and uncertainties on the part of the practitioners to the S3 guidelines ( Nieder and Strauß, 2019 ). In this constellation, it is expected that the new ICD-11 catalog 2022 will bring further change, as transsexualism will be coded in the section “Conditions affecting sexual health,” thus separating trans ∗ gender from somatic or mental illness ( Jakob, 2018 ). This was already successfully implemented in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), according to which it is only possible to speak of a disorder when there is relevant suffering due to the gender incongruence (dysphoria) ( American Psychiatric Association, 2013 ). According to MDS the assessment instructions will have to be revised after ICD-11 has been established.

Trans ∗ gender healthcare in Germany is provided in different institutions. Usually, medical services are provided in private practices. In addition, interdisciplinary healthcare supplies are available via outpatient care, such as the regional “Qualitätszirkel.” These are regional associations of multidisciplinary trans ∗ gender healthcare specialists. There are hardly any centers that offer multiprofessional treatment. The interdisciplinary care center at the University Hospital of Hamburg plays a pioneering role in this area. Some university hospitals offer specialized consultation hours, such as the specialized outpatient clinic for transsexuality and trans ∗ gender in Tübingen, which was established in October 2020. This service is primarily aimed at trans ∗ gender people before and during transition. To the best of our knowledge, there are no central registers for medical services for trans ∗ gender people. Online, there are lists of addresses maintained by interest groups. Figure 1 depicts the institutions providing treatment in Germany and the “Qualitätszirkel” (individual practices or clinics that only cover somatic needs are not listed). They offer various services: psychotherapeutic support, indication letters, medical reports to the TSG and partly interdisciplinary services. Healthcare services offered to trans ∗ gender persons are covered by the health insurance and thus are covered publically, as was decided in 1987 by the Federal Social Court, the Bundessozialgericht (BSG 3 RK 15/86). However, letters of indication from experts are necessary in order that services (e.g., hormonal treatment, surgery) are covered by the health insurance.

Figure 1. Institutions providing specialized trans ∗ gender healthcare in Germany. The map shows the location of clinics and regional associations of multidisciplinary healthcare specialists (“Qualitätszirkel”) that offer specialized trans ∗ gender healthcare in Germany, without claiming to be exhaustive. ∗ : According to the clinic‘s website only expert opinions are issued. However, this is listed differently on the website of https://transmann.de . © Bundesamt für Kartographie und Geodäsie.

How Does the Healthcare System Understand Trans ∗ gender Nowadays?

Trans ∗ gender people experience incongruence between the sex assigned at birth and their gender identity. Sex assignment is based on the external genital, which are usually defined in medical literature as indicators of the so-called biological sex. To avoid classifying non-binary gender identities as a deviation from the biological sex, the terminology “assigned gender” or “assignment gender” seems more suitable than the term “biological sex” ( Günther et al., 2019 ). Gender identity describes a person’s certainty and conviction to belong to a certain gender ( Eckloff, 2012 ). This develops during the course of a person’s life and is shaped by biological and social conditions equally ( Göth and Kohn, 2014 ). In trans ∗ gender people, gender identity does not develop in accordance with the assigned sex; the result can be a binary or a non-binary form of gender identity: Binary trans ∗ gender indicates that individuals experience themselves as belonging to the binary opposite gender (i.e., transman or transwoman). However, there are also people who feel they belong to neither the female nor the male gender and/or experience their gender on a continuum between the sexes ( Günther et al., 2019 ).

In terms of prevalence rates in European countries, similar rates have been reported, always indicating a slightly higher prevalence rate for trans ∗ women. The prevalence of the ICD-10 diagnosis of transsexualism is estimated at 1:12000 for trans ∗ women and 1:30000 for trans ∗ men in Germany ( Schneider et al., 2007 ). In Belgium, 1:12900 trans ∗ women have undergone gender-affirming surgery, while in men this ratio is approximately 1:33800 in trans ∗ men ( De Cuypere et al., 2007 ). Netherlands show similar prevalence rates (1:11900 for trans ∗ women and 1:30400 for trans ∗ men) ( Bakker et al., 1993 ). However, an increase in prevalence has been reported in several countries: in Germany, for example, a 2.6-fold increase in the number of inpatients who were diagnosed with a gender identity disorder between 2000 and 2014 has been reported (data of the German Federal Statistical Office) ( Brunner et al., 2017 ). Brunner et al. (2017) discuss the increased amount of informational martials and the facilitated access to gender-affirming therapy as a cause of the reported increase in prevalence. Whether and how destigmatization of trans ∗ gender individuals further contributes to the increased prevalence rates needs to be investigated. Unfortunately, standardized prevalence rates of trans ∗ gender individuals are rarely to be found ( Collin et al., 2016 ), as different definitions of trans ∗ gender samples lead to different results in prevalence, obscuring the systematic investigation. Furthermore, the prevalence might be underestimated, as not all trans ∗ gender persons seek gender affirming therapy ( De Freitas et al., 2020 ). After the introduction of the new ICD-11, it should be possible to record comparable prevalence rates of the diagnosis gender dysphoria instead of transsexualism.

The Healthcare System’s Influence on the Emergence and Maintenance of Suffering of Trans ∗ gender People Focused on the Situation in Germany

The German medical system has institutionalized stigmatization of non-binary people, which has to be especially considered a substantial factor of trans ∗ gender persons’ healthcare situation. This mainly applies to non-trans ∗ gender specific medical care, but also partly to trans ∗ gender healthcare. The variety of experiences of discrimination within the healthcare system have already been pointed out ( Franzen and Sauer, 2010 ; Grant et al., 2011 ; LesMigras, 2012 ; Bradford et al., 2013 ; Roberts and Fantz, 2014 ; Günther et al., 2019 ). However, since discrimination refers to distinctions that lead to, produce, or give rise to disadvantage ( Scherr et al., 2017 ), it often seems more appropriate to speak of stigmatization in the context of trans-specific healthcare in Germany. Stigmatization means the designation and marking of a deviation from a norm which is given or desired within a society ( Goffman, 1963 ). Stigmatized persons are denied the status of a normal member of society because of an attribution of characteristics marked as a deviation. Institutional stigmatization occurs within social systems or organizations, where routines in communication and actions perpetuate “normality,” which force the presentation and treatment of deviations from this norm as explicit deviations. Trans ∗ gender people experience this institutional stigmatization in modern medicine in Germany and worldwide ( Franzen and Sauer, 2010 ; Fuchs et al., 2012 ; LesMigras, 2012 ).

In itself, the structure of the healthcare system in Germany can be experienced as exclusionary by trans ∗ gender individuals: Identification documents, such as health insurance cards, may not match the gender, cause confusion in providers and can lead to misgendering which in turn is experienced as stigmatizing ( Roberts and Fantz, 2014 ). In the context of medical treatment in Germany, they presumably experience not so much discriminatory disadvantage as invalidation of their gender identity. Günther et al., suggest that exposition to the healthcare system may trigger internalized transphobia among trans ∗ gender people, due to the fact that it occasionally puts the trans ∗ gender individual under pressure to legitimize their own gender identity ( Günther et al., 2019 ).

Because of experienced and/or feared stigmatization, some people are not willing to utilize the medical system. Studies from different countries show that the use of the healthcare system in trans ∗ gender people is reduced due to fear of discrimination ( Bauer et al., 2014 ). In the US-American “national transgender survey” stigmatization experiences of trans ∗ gender persons were documented. One of the key findings reports a high likelihood of discrimination if the medical provider knows about their patients trans ∗ gender identity. They also identify a lack of knowledge by the medical providers, so most of trans ∗ gender people themselves have to inform their doctors about trans ∗ gender healthcare ( Grant et al., 2011 ). In Germany trans ∗ gender persons report that their experiences with the healthcare system depend on whether their trans ∗ identity remains hidden or becomes visible ( LesMigras, 2012 ). Stigmatizing experiences in the healthcare system are among the most common negative experiences of trans ∗ gender persons in Germany, after discrimination at the workplace ( LesMigras, 2012 ). As a result, the health of this group of people is under-supplied, as they typically leave the health system after negative experiences and seek help elsewhere ( Mizock and Lewis, 2008 ).

Due to the deeply embedded heteronormativity in Germany’s society, it is unsurprising that medical areas that are not primarily oriented toward trans ∗ gender healthcare show an unprofessional handling when they face gender identities that do not correspond to this supposed norm. Correspondingly, a study in North-Rhine-Westphalia (Germany) shows that trans ∗ gender persons were hardly satisfied with their psychotherapeutic support ( Fuchs et al., 2012 ). The same study reveals the administrative and treatment burdens caused by the MDS review procedure. It has also been shown, that the institutional pathologizing of trans ∗ identity is experienced as a tremendous burden by trans ∗ gender people ( LesMigras, 2012 ). As outlined in section “The Evolution and Current Healthcare for Trans ∗ gender in Germany,” the German healthcare system has been developing new ways of dealing with trans ∗ gender healthcare. It is in a transition period between strict regulation and self-determination of the trans ∗ gender community. Studies on the fears and wishes of the trans ∗ gender community for multiprofessional treatment centers (as the one in Hamburg) show that also on the part of the treatment providers this development is being worked on and the offers are being adapted to the needs of the trans ∗ gender community ( Eysell et al., 2017 ).

Trans ∗ gender people depend on the healthcare system as they require medical professionals before, during and after gender affirming therapy. Even after a successful transition, psychotherapeutic and somatic care must be ensured. Due to hormone therapy, trans ∗ gender persons have a different lifetime risk profile for cardiovascular diseases ( Aranda et al., 2019 ; Dutra et al., 2019 ; Pyra et al., 2020 ). The risk for sex-hormone dependent cancers is not higher during gender-affirming hormone therapy, but the cancer screening recommendations have to be considered in trans ∗ gender people as well, i.e., prostate cancer screening in transwomen or breast and cervical cancer screening in transmen ( McFarlane et al., 2018 ). Because of this need, it is alarming that the stigmatization in the healthcare system increases the chance for trans ∗ gender people to avoid medical care and balk preventive measures, such as cancer screenings ( Günther et al., 2019 ; Weyers et al., 2021 ).

In addition, studies show that after gender-affirming therapy, psychological stress can also occur, which may lead to increased suicidality ( Rolle et al., 2015 ; Wiepjes et al., 2020 ). The lifetime prevalence of suicidality is also affected – amongst other variables – by negative experience with medical providers ( Haas et al., 2014 ).

Psychotherapeutic services should also strive to offer gender-sensitive counseling in order to adequately address internalized transphobia, specific role conflicts, and so forth. The need for specialized counseling usually is not met after transition, as trans ∗ gender persons are constantly confronted with their minority status in a binary, heterosexual environment ( Verbeek et al., 2020 ). Unfortunately, specialized training programs for psychotherapists are hardly established. Since medical professionals are usually not trained in gender-sensitive medicine and may be out of their depth with regard to the healthcare of trans ∗ gender persons, this ongoing stigmatization comes as no surprise. Therefore, gender sensitive medicine must become a part of the medical curriculum. There seems to be an interest on the part of medical students ( Turner et al., 2014 ). Finally, gender sensitive medicine has to be implemented in the standard medical care in Germany ( Chase et al., 2014 ).

Medical Care Services and Barriers for Trans ∗ gender Individuals in Europe

As we propose, the institutionally co-generated psychological strain on trans ∗ gender persons, promotes comorbidities and further increases economic costs. It seems imperative that stigma-free and need-oriented trans-specific treatment is provided by trained personnel. Only then can we reasonably expect that the psychological distress due to gender dysphoria can be minimized and fused conflicts can be addressed e.g., via psychotherapy. There is evidence for a reduction of distress through access to gender-affirming therapy ( Bränström and Pachankis, 2020 ; Almazan and Keuroghlian, 2021 ).

The mission statement of the European Professional Association for Transgender Health (EPATH), a sub-organization of the World Professional Association for Transgender Health (WPATH), envisions the establishment of uniform European healthcare for trans ∗ gender persons. By drafting a “standard of care” position paper, EPATH tries to formulate a uniform guideline for trans ∗ gender sensitive health care beyond transition. The guideline furthermore establishes basic principles, addressing medical professionals. There is a consensus that healthcare providers worldwide should adhere to these basic principles, regardless of socio-cultural norms and legal requirements of their respective country. Inter alia , EPATH urges medical personnel to treat trans ∗ gender persons respectfully and in a non-pathologizing manner. Access to treatment options should be ensured and medical personnel should be further trained in gender-sensitive medicine ( Coleman et al., 2012 ).

However, uniform and comprehensive care for trans ∗ gender persons is far from guaranteed in Europe, as the legal and medical situation is highly diverse: While some countries have been trying to ensure appropriate treatment of trans ∗ gender persons in the legal and medical domain, trans ∗ gender people in other countries are faced with persecution and discrimination ( ILGA Europe Annual Review, 2021d ). Apart from that, a legal and medical situation that considers the needs of trans ∗ gender people does not necessarily imply that sufficient medical care is provided or that medical staff are sufficiently informed. While there are specialized treatment centers in many European countries nowadays, trans ∗ gender individuals generally face the problem of long waiting times due to the structural lack of healthcare providers in the area of gender-affirming treatment services. In Netherlands treatment options (i.e., diagnostic classification, subsequent gender-affirming therapy such as hormone therapy, gender-affirming surgery) are offered in health centers (Amsterdam UMC, Groningen UMC and Radboud UMC Nijmegen). Like the center in Hamburg, they provide an interdisciplinary treatment – the so-called “gender team.” However, these centers are far from meeting the demand and a lack of healthcare providers in Netherlands has been pointed out recently ( Verbeek et al., 2020 ). In Belgium, care is also provided in healthcare centers (Belgien Universitär ziekenhuis Ghent, Université libre de Bruxelles and Le centre hospitalier universitaire de Liège), with the center in Ghent offering interdisciplinary care ( Elaut, 2014 ). In contrast to Germany, hormonal treatment in Belgium is already possible during full-time real-life experience ( Steinmetzer and Groß, 2008 ). Here, too, the long waiting times have been pointed out as problematic and as an obstacle to the access of appropriate services ( Motmans et al., 2010 ). Specialized care centers in England, Scotland, and Northern Ireland are listed by Vincent (2018) . He points out that trans ∗ gender persons have the longest waiting times of all patients in need of specialized treatment services. In Spain, the healthcare is installed in multidisciplinary gender units in different communities all over the country and the Canary Islands ( Gómez-Gil et al., 2019 ). New healthcare models deviate from the central multidisciplinary gender units, for example by offering gender-affirming healthcare without psychological assessment. These new healthcare models are the subject of controversy, because the decentralization can be considered a missed opportunity: (a) for research and (b) to collected data to evaluate the quality of healthcare ( Gómez-Gil et al., 2020a , b ).

The procedure for gender-affirming surgery in Denmark is prescribed by the Danish Health Authority and is centralized in three clinics (e.g., The Sexological Clinic, Ringshospitalet Copenhagen) ( ILGA Europe Annual Review, 2021c ). Italy is a positive example of a publicly accessible database of medical care professionals. On the website https://www.infotrans.it/ , published in 2020, trans ∗ gender people can find out about treatment services ( ILGA Europe Annual Review, 2021b ).

The situation in Poland stands out as a negative example in a discrepancy to the, as not sufficiently marked, but existing care situation in most European countries. There, no medical care for trans ∗ gender persons is guaranteed. In addition, there is talk of a hate campain against the LGBTIQ community ( ILGA Europe Annual Review, 2021a ).

Overall, healthcare in Europe is taking important steps toward depathologization, and many countries are attempting to establish the requirements of WPATH/EPATH. Worldwide, however, conditions remain poor and self-determination rights are denied to the trans ∗ gender community. In some countries trans ∗ gender persons are still criminalized (e.g., Indonesia, Niger, Malaysia, United Arab Emirates).

Key Findings

The article reviews the medical care situation for trans ∗ gender people nowadays and it provides a more detailed description of the situation in Germany. Three main deficiencies were identified, that are linked to medical care for trans ∗ gender persons in the German healthcare system: (1) A lack of specialized medical care to support transition. Mental comorbidities could be reduced by individualized support during transition. However, this is usually hindered by significant organizational and institutional barriers. Deficits in the structure of specialized healthcare services in Germany and Europe have been pointed out. There is a lack of specialized care offers that ensure a safe place for good care and that alleviate individual suffering through a professionally accompanied transition. (2) A lack of gender-sensitive psychotherapeutic support before and after transition, which could address the trans ∗ gender specific dysfunctional internalization processes in a patient-oriented, professional manner. (3) A lack of sensitivity to special treatment needs in post-transition healthcare. We elaborated that even after transition, a non-discriminatory integration into the healthcare system remains necessary. Due to exclusively binary gender thinking, medicine is prone to institutional stigmatization. Accordingly, trans ∗ gender people are frequently confronted with deficits and hurdles with the safeguard of their health. The multifactorial condition of suffering is modeled in Figure 2 .

Figure 2. Multifactorial condition of suffering. © Bundesamt für Kartographie und Geodäsie.

Perspective

We see an urgent need for the establishment of comprehensive gender-affirmative healthcare. We propose three starting points: (1) A nationwide structure of specialized treatment centers for trans ∗ gender healthcare is needed. In particular, the problem of unacceptably long waiting times must be addressed. (2) Specific sexual medicine training at an early stage (i.e., at university level during education and later on in specialist training) should lay the groundwork to minimize the institutional stigmatization of trans ∗ gender individuals. (3) Finally, we call for the establishment of psychotherapeutic specialization as well as further education programs to support appropriate treatment of the diverse and multifactorial psychological issues of trans ∗ gender people.

It should be pointed out, that through increased cooperation between medical providers and advocacy groups (e.g., Transgender Europe, TGEU), the European healthcare system can be transformed into a system based on self-determination and informed consent. It is time to face and address the many faceted barriers trans ∗ gender people are facing when confronted with the healthcare system in different European countries (and probably world-wide).

In Germany we see a significant progression within the medical system toward the recognition of the trans ∗ gender community and its needs in the recent years. The implementation of the new S3 guidelines is becoming more and more important and the trans ∗ gender community is becoming more and more involved. Unfortunately, this development has not yet reached all areas. The new ICD catalog in 2022 will be an important step to further improving healthcare of trans ∗ gender individuals. We hope to contribute to establishing improved, gender-sensitive medical care in line with the variable demands of trans ∗ gender people.

Data Availability Statement

The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.

Author Contributions

NG prepared the first draft of the manuscript. All authors contributed to critically revising and editing the content of the manuscript and approved the final version of the manuscript for submission.

MG, CL, UH, and BD were supported by the German Research Association (DFG, DE2319/2-4).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We thank Janina Richter, Tobias Schwippel, and Rebecca Popp for their valuable input. Also, a special thanks to Philipp Rhein, who helped reviewing the topic from a sociological perspective.

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Keywords : transgender, transidentity, transsexualism, healthcare, internalized homonegativity, gender-affirmative healthcare

Citation: Guethlein N, Grahlow M, Lewis CA, Bork S, Habel U and Derntl B (2021) Healthcare for Trans*gender People in Germany: Gaps, Challenges, and Perspectives. Front. Neurosci. 15:718335. doi: 10.3389/fnins.2021.718335

Received: 31 May 2021; Accepted: 11 August 2021; Published: 07 September 2021.

Reviewed by:

Copyright © 2021 Guethlein, Grahlow, Lewis, Bork, Habel and Derntl. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nora Guethlein, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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• Copy URL https://www.pbs.org/newshour/world/german-parliament-approves-measure-making-it-easier-for-transgender-people-to-change-legal-name-and-gender

German parliament approves measure making it easier for transgender people to change legal name and gender

BERLIN (AP) — German lawmakers on Friday approved legislation that will make it easier for transgender, intersex and nonbinary people to change their name and gender in official records.

The “self-determination law,” one of several social reforms that Chancellor Olaf Scholz’s liberal-leaning coalition government pledged when it took office in late 2021, is set to take effect on Nov. 1.

WATCH: What to know about Germany’s far-right politics and protests against its rise

Germany, the European Union’s most populous nation, follows several other countries in making the change. Parliament’s lower house, the Bundestag, approved it by 374 votes to 251 with 11 abstentions.

The German legislation will allow adults to change their first name and legal gender at registry offices without further formalities. They will have to notify the office three months before making the change.

The existing “transsexual law,” which dates back four decades, requires individuals who want to change gender on official documents to first obtain assessments from two experts “sufficiently familiar with the particular problems of transsexualism” and then a court decision.

Since that law was drawn up, Germany’s top court has struck down other provisions that required transgender people to get divorced and sterilized, and to undergo gender-transition surgery.

“For over 40 years, the ‘transsexual law’ has caused a lot of suffering … and only because people want to be recognized as they are,” Sven Lehmann, the government’s commissioner for queer issues, told lawmakers. “And today we are finally putting an end to this.”

The new legislation focuses on individuals’ legal identities. It does not involve any revisions to Germany’s rules for gender-transition surgery.

The new rules will allow minors 14 years and older to change their name and legal gender with approval from their parents or guardians; if they don’t agree, teenagers could ask a family court to overrule them.

In the case of children younger than 14, parents or guardians would have to make registry office applications on their behalf.

After a formal change of name and gender takes effect, no further changes would be allowed for a year. The new legislation provides for operators of, for example, gyms and changing rooms for women to continue to decide who has access.

Nyke Slawik, a transgender woman elected to parliament in 2021 for the Greens, one of the governing parties, recounted her experience of going through the current system a decade ago. She said she had had enough of being asked “is that your brother’s ID?” when she had to identify herself.

“Two years, many conversations with experts and one district court process later, it was done — the name change went through, and I was nearly 2,000 euros ($2,150) poorer,” she told lawmakers. “As trans people, we repeatedly experience our dignity being made a matter for negotiation.”

The mainstream conservative opposition faulted the legislation for what it described as a lack of safeguards against abuse and a lack of protection for young people. Conservative lawmaker Susanne Hierl complained that the government is “ignoring the justified concerns of many women and girls.”

“You want to satisfy a loud but very small group and, in doing so, are dividing society,” Hierl said.

Martin Reichardt of the far-right Alternative for Germany blasted what he called “ideological nonsense.”

Justice Minister Marco Buschmann said in a statement that “there are numerous precautions against possibilities of abuse, however improbable they may be.” He insisted that the new law takes into account the interests of the whole of society and said “much less will change with this law than some say.”

Among others, Denmark, Norway, Finland and  Spain  already have similar legislation.

READ MORE: Spain parliament approves menstrual leave, teen abortion and transgender protections

In the U.K., the Scottish parliament in 2022 passed a bill that would allow people aged 16 or older to change the gender designation on identity documents by self-declaration. That was vetoed by the British government, a decision that Scotland’s highest civil court upheld in December.

In other socially liberal reforms, Scholz’s government has  legalized the possession  of limited amounts of cannabis; eased the rules on gaining German citizenship and ended restrictions on holding dual citizenship; and ended a ban on doctors “advertising” abortion services. Same-sex marriage was already legalized in 2017.

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

• Open access
• Published: 30 May 2024

The effects of gender discrimination on medical students‘ choice of specialty for their (junior) residency – a survey among medical students in Germany

• Jule Stock 1 &
• Andrea Kaifie 1 , 2  

BMC Medical Education volume  24 , Article number:  601 ( 2024 ) Cite this article

132 Accesses

Metrics details

Gender discrimination is known to affect societies in many different settings. Medical education is no exception. This study focusses on the consequences, gender discrimination can have on medical students and their choice of (junior) residency specialty.

An online questionnaire was developed and distributed among the 40 medical faculties in Germany. The study population contained medical students in their fifth and sixth academic year.

The survey’s participants consisted of 759 students from 31 universities. Female medical students experienced significantly more gender discrimination compared to their male colleagues (f = 487, 87.9% vs. m = 76, 45.8%, p  < 0.0001). The specialties with the most reported gender discrimination were family medicine (f = 180, 42.9% vs. m = 15, 23.8%, p  < 0.05), followed by surgery (f = 369, 87.4% vs. m = 44, 69.8%, p  < 0.05), internal medicine (f = 282, 67.3% vs. m = 37, 58.7%, ns), orthopaedics/casualty surgery (f = 270, 65.1% vs. m = 32, 50.8%, p  < 0.05), and gynaecology (women (f = 142, 34.1% vs. m = 34, 54.0%, p  < 0.05). Gynaecology was the only specialty, men experienced more discrimination compared to women. Among the students that ever changed their specialty of choice (f = 346 (73.3%) m = 95 (72%)), significantly more women than men claimed gender discrimination to be one of the main three reasons for their specialty choice (f = 42, 12.1% vs. m = 1, 1.1%, p  < 0.05). In addition, 53 students (f = 50 (10.6%) m = 3 (2.3%)) stated to rule out a specialty from the beginning due to gender discrimination.

Gender discrimination is frequently experienced by medical students in Germany. It influences their choice of medical specialty directly. Our data suggest a fundamental problem that proposes and implicates certain specialties to be attractive for only one gender.

Peer Review reports

Since they have first been accepted to German medical universities in the last years of the 19th century, the number of female medical students has increased over the time. While in 1993 45.7% (41,417) of the medical students in Germany were women, they have obtained the majority of 64.36% (69,597) of the total 108,130 medical university places in 2022 [ 1 ]. The admission criteria of German medical schools might be of interest as one possible reason for this feminization of the medical field. Apart of some exceptions, there are three main centrally managed admission categories. Students can be admitted either based on the final school grade, the time of waiting for admission or the university’s choice (often based on grades, additional tests or interviews). Since the average of female students tend to reach slightly higher final grades than their male fellow students (f = 2.27 vs. m = 2.45) [ 2 ], they might nowadays secure a place in medical school more easily. However, that does not explain the worldwide increase of women in the medical field [ 3 , 4 ], as the admission criteria to medical schools differ between the countries. For Germany, a representative from an official medical association came to the conclusion that the high workload and responsibility and the worse pay in comparison to less responsible jobs might be a reason for the feminization as it became less attractive for men [ 5 ].

This high percentage of women in medical schools is however not represented in every medical specialty. Statistics of resident German doctors show, that women are far less often found in the fields of urology, orthopaedics and surgery, while less men practice as paediatricians or psychiatrists [ 6 ].

That raises the question, which factors influence the medical students’ decision, when it comes to choosing their medical specialty. There are significant differences on specialty choices between female and male students, especially for paediatrics, orthopaedics and surgery [ 7 ]. The lack of role models of the own gender in the different specialties might be one reason [ 8 ], making the genders’ predominance in certain specialties a self-fulfilling prophecy. A study, that has been carried out in the US, identifies gender discrimination as another influencing factor on American medical students’ specialty and residency choice [ 9 ].

Gender discrimination is a frequently experienced phenomenon amongst medical students [ 10 , 11 , 12 , 13 , 14 , 15 ], that is known to have negative psychological impacts, such as an increased risk of depression, anxiety, emotional exhaustion or substance abuse [ 11 ]. A German pilot study in the field of gender discrimination at a medical school indicated, that gender discrimination can lead to negative perceptions of ones’ opportunities, as well [ 10 ]. Their research led the authors of this study believe, that gender discrimination, that was predominantly experienced by women, can have influence on the students’ future career path. However, the nature of this influence was not specified.

To contribute against inequality in medical education, this study is going to examine the gender discrimination experiences of medical students throughout Germany and evaluate whether it has a significant influence on the specialty choice and therefore the predominance of one gender in certain specialties.

Development of questionnaire

The online questionnaire developed contained 34 questions and was mainly adapted from pre-existing questionnaires that have already been used in the field [ 10 , 16 ]. The participants were divided into two answer categories, one asking about experienced gender discrimination and one about witnessed gender discrimination. Prior to the questions about gender discrimination, the questionnaire gave a short definition of gender discrimination and microaggressions to sensitize the participants and to help them categorise their experienced or witnessed incidents of discrimination. For some variables, examples were given for explanatory reasons. For example: “Unwanted persistent affections (e.g. flirting, asking on dates)”, “public humiliation (e.g. to show up somebody on rounds)”.

The questionnaire was divided into sections including:

Sociodemographic data: university, phase of studies, gender, age (religion and parents’ highest educational qualification were optional).

Current specialty choice and desirable work qualities: qualities had to be assessed with a 4-point Likert scale “unimportant, less important, important, very important”.

Experienced or witnessed gender discrimination: form, aggressors, setting.

Perceptions of dis-/advantage because of gender.

Changes made concerning the specialty of choice and their reasons.

Receiving advise for/against choosing a specialty due to the gender.

When asking about forms, setting or aggressors of discrimination, a five-point Likert scale was used, containing the values “never, rarely, occasionally, often, very often”. The questions concerning gender discrimination were adapted from the questionnaire used in the research article of Jendretzky et al. [ 10 ]. The items, inquiring the specialty choices and desirable work qualities, were partially used from the “Berufsmonitoring Medizinstudierender 2018” [ 16 ], which questioned approximately 13000 medical students in Germany on work expectations and career goals. For settings or forms of gender discrimination, it was possible to give multiple answers due to possible multiple experienced or witnessed incidents. We pretested the questionnaire in a group of 15 voluntary participants and added small alterations in the final quationnaire.

Data collection

Data was collected over a period of 44 days from 2023/01/16 to 2023/02/28. For the questionnaire distribution and data assembly we used SoSci Survey [ 17 ], accessible for the participants via the website www.soscisurvey.de . The link for the questionnaire was distributed among 40 German medical faculties by E-Mail, WhatsApp, Instagram and online fora. To increase the response rate, the faculties were asked to post reminders to the survey after about 25 days, what led to another small peak of responses. Altogether, students from 31 medical faculties filled out the questionnaire. To rule out participation bias, the study’s focus on gender discrimination was not apparent in the cover letter. It was introduced after the sociodemographic data and specialty choice questions. The cover letter stated, that the students will be participating in “a survey to figure out, which factors influence medical students’ decision when it comes to choosing a specialty for the junior-/residency.”

Statistical analysis

The data collected via soscisurvey.de was downloaded and processed in Excel. The questionnaire’s Likert scale values of the questions concerning:

the experienced or witnessed discrimination (whether it ever happened, forms, setting and specialties).

regarding the own gender as dis-/advantage.

the gender of the aggressors.

feeling like having to put in more effort compared to the other gender.

were dichotomised into “never” or “ever” experienced. The queried desired work qualities were dichotomised into “less important” (un- and less important) or “important” ((very) important). Due to the small total number of participants that identified as diverse ( n  = 8), the group was not included in descriptive statistics or tests for statistical significance. The statistical analysis was carried out with the use of “SAS OnDemand for Academics”. The categorical variables were analysed using frequencies. The Chi 2 -Test was used to determine significant differences between the male and female students, indicating statistical significance with a value of p  < 0.05.

Participants

The participants (Table  1 ) of this study included medical students from 31 of 40 German medical faculties from the ninth semester to the practical year (the last academic year in German medical school) covering enrolled students from the 5th and 6th year. 759 participants were matching these criteria, 603 of them completed the questionnaire. The ratio between the gender categories in the study population differed from that of all German medical students with a higher proportion of female students in our study (f = 63.8%, m = 36.2%, d = no data for Germany [ 1 ] vs. f = 76.0%, m = 22.9%, diverse = 1.1% in our study population).

Current specialty of choice and desirable work qualities

In addition to the students` current specialty of choice (Table  1 ), participants were asked to state the personal importance of certain statements regarding their future work. We observed significant differences between men and women in four of the twelve categories. Women found “flexible working hours” (f = 381, 68.8% vs. m = 92, 56.4%, p  = 0.0035) as well as “regular working hours” (f = 462, 83.2% vs. m = 124, 75.6%, p  = 0.027) and “knowing not only the medical history, but also the life story of a patient” (f = 353, 63.6% vs. m = 78, 47.6%, p  = 0.0002) significantly more important compared to men. In.

the group of men, “good career options” ( n  = 110, 67.5%) were regarded as significantly more important compared to women ( n  = 273, 49,4%, p  < 0.0001). Most often considered as important (86.4%) was “achieving a good work-life balance”, with no statistically significant difference between men and women.

Gender discrimination

Gender discrimination among medical students during their academic career was experienced significantly more often by women than men (f = 487, 87.9% vs. m = 76, 45.8%, p  < 0.0001). Men, that never experienced gender discrimination themselves, stated more often to have witnessed gender discrimination than the women that have never been discriminated (f = 25, 37.9% vs. m 64, 72.7%).

As shown in Fig.  1 , the specialties, women mostly experienced gender discrimination in were family medicine (f = 180, 42.9% vs. m = 15, 23.8%, p  = 0.0041), surgery (f = 369, 87.4% vs. m = 44, 69.8%, p  = 0.0002), internal medicine (f = 282, 67.3% vs. m = 37, 58.7%, ns) and orthopaedics/casualty surgery (f = 270, 65.1% vs. m = 32, 50.8%, p  = 0.0287). Except for internal medicine, gender discrimination, experienced by men, was significantly less frequent compared to women. Men stated to have been discriminated in gynaecology significantly more often than women (f = 142, 34.1% vs. m = 34, 54.0%, p  = 0.0022).

The five most common specialties to experience gender discrimination itemised by gender

Table 2 shows the settings where n  = 560 students were either discriminated themselves or witnessed gender discrimination. The three most often selected settings were nursing practice internship ( n  = 465, 83%), clinical traineeships ( n  = 464, 82.9%) and university lectures and classes ( n  = 434, 77.5%). Altogether, n  = 47 (8.4%) of the participants reported to have experienced gender discrimination in the nursing practice internship “very often”. 78.1% ( n  = 139) of students in their junior residency witnessed or experienced gender discrimination in this setting.

Experienced as well as witnessed forms of gender discrimination can be found in Table  2 . Women have experienced gender discrimination mainly in form of degrading jokes and insults (f = 409, 93.4% vs. m = 45, 69.2%, p  < 0.0001), degrading gestures (f = 251, 57.3% vs. m = 25, 38.5%, p  = 0.0044), degrading nicknames (f = 389, 88.8% vs. m = 49, 75.4%, p  = 0.0021), unfounded questioning of one’s knowledge (f = 347, 79.2% vs. m = 38, 58.5%, p  = 0.0002), unwanted touch (f = 266, 60.7% vs. m = 28, 43.1%, p  = 0.007) and unwanted inappropriate compliments (f = 329, 75.1% vs. m = 33, 50.8%, p  < 0.0001) significantly more often compared to the male students. Male students reported to have experienced, more insults and verbal abuse (f = 31.5% vs. m = 35.4%, n.s.) and public humiliation (f = 39.7% vs. m = 41.5, n.s.).

The main aggressor of experienced and witnessed gender discrimination were patients ( n  = 406, 72.9%) followed by senior physicians ( n  = 401, 72%) ( Fig.  2 ).

Most frequently named aggressors of combined, sum of experienced and witnessed gender discrimination incidents

In addition, participants were asked how often they experienced gender discrimination by aggressors of their own gender and/or of the other gender (Table  2 ). Men were significantly more often discriminated by their own gender compared to women (women discriminated by women: n  = 245, 58.3% vs. men discriminated by men: n  = 51, 82.3%, p  = 0.0003). In contrast, women were significantly more often discriminated by the other gender (women discriminated by men: n  = 413, 98.6% vs. men discriminated by women: n  = 56, 90.32%, p  = 0.0001).

Furthermore, participants were asked whether they have ever perceived their gender as an advantage or disadvantage during their study of medicine (Table  2 ). There was no significant difference between the perception of their gender as an advantage between male and female students (f = 336, 71.2% vs. m = 90, 68.2%, n.s.). In contrast, the female students stated significantly more often, that they frequently assessed their gender as a disadvantage, than men (f = 387, 82% vs. m = 64, 48.5%, p  < 0.0001).

Changes in the desired specialty

The medical students were also asked, whether they have ever changed their specialty choice during their medical education. Among the female students, n  = 346 (73.3%) reported to have changed their specialty choice, n  = 194 (41.1%) of them even multiple times. Male students had similar percentages with n  = 95 (72%) ever changing their specialty choice and n  = 51 (38.6%) reconsidering multiple times. (Table  2 ).

Gender discrimination was the reason for n  = 50 (10.6%) women and n  = 3 (2.3%) men to not consider a specialty as a career option in the first place (Table  2 ). The main reason for changing the initially desired speciality were working hours (f: 51.4%, m: 43.2%) and false expectations of the specialty (f: 35%, m: 42.1%) (Fig.  3 ). The only statistically significant difference between men and women in terms of changing the speciality was gender discrimination. Women chose gender discrimination to be among their three main reasons for a chance of a previously chosen specialty significantly more often than men (f = 42, 12.1% vs. m = 1, 1.1%, p  = 0.0013) (Fig.  3 ). Altogether, n  = 6 (1.7%) of the women reported that gender discrimination was the only reason for changing the desired speciality. None of the men in the study reported that gender discrimination was the only reason for changing their speciality choice.

Percentages of participants selecting a reason as one of their 3 main reasons for their change of specialty

N  = 268 (57.1%) women received advise to choose a certain specialty only because of their gender compared to n  = 21 male students (16.2%, p  < 0.0001)(Fig. 4.1). Even more women were told not to pursue a career in a certain specialty because of their gender ( n  = 330, 70.4%, Fig. 4.3). Male students did also experience more advice against certain specialties, that toward others (against: n  = 27, 20.8% vs. towards: n  = 21, 16.2%). Men reported significantly more often (m = 9, 6.9% vs. f = 1, 0.2%, p  < 0.0001) to have been advised to choose the specialty of surgery, because of their gender and not to start their career in the specialties of gynaecology (m = 20, 15.4% vs. f = 10, 2.1%, p  < 0.0001) or paediatrics (m: n  = 7, 5.4% vs. w: n  = 7, 1.5%, p  = 0.0093) (Fig. 4.2 and 4.4), while women were told to avoid surgery (f = 283, 60.3% vs. m = 3, 2.3%, p  < 0.0001) and orthopaedics (f = 175, 37.3% vs. m = 0, 0%, p  < 0.0001) (Fig. 4.2 + 4.4) (Fig. 4 ).

Percentages of participants that have ever been advised to or against a certain specialty, analysed by gender

Our Germany wide survey showed that gender discrimination is a present part for medical students during their training. In comparison to a single centred study in Germany in 2020 [ 10 ], the participants at our study reported experienced or witnessed gender discrimination more frequently. The reasons for that are diverse. First, the presence of gender discrimination in all forms of media has even increased in the past 3 Years. Second, our study population was approximately two times larger and we only included 5th and 6th year students in our study population. Especially the ladder point might be of significance because students who are more advanced in their medical education might naturally have had more situations were a discrimination incident could occur.

The aggressors of gender discrimination were people that have a high standing in hospital’s hierarchy and/or the students have much contact to. That might explain that senior doctors and patients were the most frequently named aggressors. While students depend for a proper education and fair grading to a certain degree on senior doctors [ 14 ], patients as aggressors might reflect that gender discrimination is not only a problem of medical education, but of society, as well. Similar aggressor distribution was found in a Swedish study amongst final year medical students [ 12 ].

Male students showed to have significantly higher career intentions, either reaching for higher positions [ 10 ] or declaring good career options to be an important factor for the future specialty, which was confirmed in another study [ 16 ]. Interestingly a good work-life-balance was most often considered to be important for both men and women, what might seem counterintuitive. This leads to the question whether men and women define a good work-life-balance equally, or whether the goal of a good work-life-balance has become less of a gender-based goal, but more of a demand of this generation.

The gender of students that have witnessed gender discrimination more frequent were surprisingly men. Reasons could include the tendency of women to downplay occurred gender discrimination incidents, when confronted repeatedly with a hostile environment [ 14 , 18 ]. This hypothesis is plausible especially in terms of the high quantities of gender discrimination during medical education [ 10 , 12 , 15 , 18 , 19 ] and that makes it quite unlikely for medical students to have never ever witnessed gender discrimination. By giving a definition of our understanding of gender discrimination and microaggressions, we tried to minimise the influence of different perceptions of discrimination on the reported incidents. However, a definition might not exclude that influence in total, meaning the subjective perception of gender discrimination remains an important bias factor that has to be considered when interpreting our results.

While gender discrimination is not one of the most frequently reported reasons, it still influenced the specialty choice of in particular for women. These findings are contrary to a similar study with medical students in the USA, that observed men to be more perceptible of experienced gender discrimination [ 9 ]. In both studies the influence of gender discrimination on the students’ specialty choice was determined by self-assessment by the participants and is therefore a subjective evaluation. Furthermore, the participants in our study were given multiple examples for reasons that might have affected their choice against one specialty, instead of just asking about the influence of the gender discrimination on their decision. The participants of a Swedish single centre study reported, that an important coping mechanisms of gender discrimination was the avoidance of unpleasant situations, people and places [ 14 ]. This might imply avoiding a certain speciality due to experiences gender discrimination.

The questionnaire also included advises the students were given concerning their future specialty, that might have an influence on their specialty choice, as well. Interestingly, female participants were more likely to be advised to a speciality where they also saw their career future, such as gynaecology, paediatrics, anaesthesiology or family medicine. Male medical students did not prefer to be surgeons as often as they were advised to. However, the advised avoidance of paediatrics and gynaecology, was similar to the preferred speciality as they were less popular among male students.

With the advice towards female students to not choose surgery or orthopaedics as a career option, the advisors named two of the specialties where most incidents of gender discrimination were reported. These findings propose a connection even though only 12.9% of students stated, that gender discrimination influenced their decision on their future speciality. Women’s predominance in obstetrics-gynaecology or paediatrics can be found across countries in various studies [ 6 , 7 , 20 ].

Are they still stereotypical relicts? In the case of orthopaedic surgery, women found the specialty to be unappealing because of the work/life balance and also perceived themselves as physically too weak [ 21 ]. Although there might be no objective reason for not choosing a certain physically demanding medical speciality, subjective reasons might play an important role.

In the study of Gjerberg et al. [ 22 ] the lack of flexibility in the work environment in the men dominated specialty of general surgery was observed as a further reason for not completing their training. She points out, that even though gynaecology and general surgery have similar demands on the doctors, the number of female doctors between these specialities differ a lot. This suggests that the specialties that are more attractive for women may have already found ways to be more attractive, for example by more flexible work schedules to, for example raise children.

Women have structural disadvantages when it comes to very time and capacity demanding medical specialties, because they are expected to care for their family, house and children on top of their work [ 4 , 23 ]. In Germany for example, partners with unequal incomes have tax advantages.- Structurally intended the work distribution becomes unbalanced, even leading to women at work having to step back or risking burn-outs [ 23 ]. With this in mind, female medical students might choose their specialty according to their upcoming tasks in the family life.

The strong association between female medical students’ decision for a specialty and the amount of women as role models in that specialty was found by Neumayer et al. [ 8 ] indicating that the lack of role models in certain specialties, presumably for men and women, might be an important influencing factor for the students’ specialty choice, as well [ 21 ].

In contrast to the reasons for a change of the desired specialty in our analysis, other studies have identified multiple other reasons for medical students, that reportedly influenced their decision. Mohamed et all [ 24 ] found, based on a questionnaire at a Saudi-Arabian college of medicine, that the selection of specialty were economic anticipations as well as personal interest. A Slovenian study compared less subjective determinants like social backgrounds and character traits among medical students with the same specialty of choice and found resemblances among these [ 25 ]. In addition to the results in our study, a single centre study in the United Arab Emirates [ 20 ] confirmed that the atmosphere, a medical student experiences while engaging with a specialty and, to a lesser degree, the recommendations received by friends and family do affect the medical students’ decision about their specialty choice.

Limitations

More women than men participated in our study presumable due to bias of interest in the topic, meaning the results for women are more representable than for the men. Furthermore, the amount of replies from the different universities varied a lot. Even though all of the universities were reached by at least one way of contact, the distributions’ efficiency towards students differed, so that not every German medical student matching our study population’s criteria could be reached.

With the subject of discrimination, there is always a variation on peoples’ perception of discrimination incidents and their severity. The answers to the questionnaire must be regarded as subjective descriptions. Nevertheless, it is important to acknowledge the subjective discomfort of students, as this subjective impression is, what influences decisions, such as career pathways.

Gender discrimination plays an important role in medical students’ education and in choosing their striven specialty. With the increasing numbers of female doctors and the impending shortage of doctors in Germany, the unequal gender dispersion amongst the specialties, as it is now and as the participants’ current specialty choices suggest, could increase the problematic situation even further. Specialties should therefore aim to be equally attractive to both, men and women or at least to not repel genders. Other than gender discrimination it is important to establish a social structure that allows all people to combine work, family and free time in a non-overwhelming manner, so that all doctors that were thoroughly trained can work and stay healthy for a long time.

Furthermore, it should be in our societies greatest interest to train well educated doctors that choose their specialty based on their interest and talents and not because of a social role picture that was forced upon them. As in former times all medical specialities were dominated by men, it can be expected, that female doctors will also conquer currently male dominated fields.

Gender discrimination is a problem in many aspects of society and is fought by various measures. The medical faculties, as a place of education and therefore with impact on the future doctors, must support their students in addressing gender discrimination incidents. There are already Equality-Offices at most German universities, that offer assistance dealing with discrimination. Students should have low-threshold access to reporting systems for gender discrimination as well as fast help when needed.

Due to the raising awareness about gender stereotypes and discrimination, that might have been less imminent in the past, it is important as well to address the potential aggressors of such discrimination to raise their awareness on the topic, create a great understanding of it and prevent incidents from occurring.

Data availability

The study’s data is available from the corresponding author on reasonable request.

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J.S. and A.K. conceptualised the study and agreed on its’ methods. J.S. and A.K. designed the questionnaire. J.S. distributed the questionnaire, collected, analysed and visualised the data. J.S. wrote the original Paper, J.S. and A.K. reviewed and edited the Paper. A.K. supervised the study. All authors have read and approved the final manuscript.

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Stock, J., Kaifie, A. The effects of gender discrimination on medical students‘ choice of specialty for their (junior) residency – a survey among medical students in Germany. BMC Med Educ 24 , 601 (2024). https://doi.org/10.1186/s12909-024-05579-9

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DOI : https://doi.org/10.1186/s12909-024-05579-9

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