• In short: Only a handful of Australian surgeons offer certain gender-affirming procedures, meaning transgender people are waiting for years or seeking options overseas
• What's next? An application has been made to list gender-affirming surgeries as specific Medicare items, to help address high costs and low availability

For trans woman Abbie Clark, feelings of gender dysphoria have been coming and going since she was a kid.

She didn't initially know what it meant to be trans, but she knew she would rather be a woman than a man.

"When I wanted to transition, I didn't know where to go," the 30-year-old Ballarat woman said.

"I didn't know what service I needed to look at, I didn't know who I needed to talk to."

Ms Clark had surgery on Trans Day of Visibility last year, three years after starting hormone treatment and a year-and-a-half after her consultation with the surgeon.

Transgender Australians are spending years waiting for gender-affirming surgery, which is still required in some states to change birth certificate gender markers.

Gender-affirming surgery refers to a variety of procedures, including mastectomies, breast augmentation, facial feminisation and vocal chord surgery, as well as genital surgery.

Genital surgeries, such as vaginoplasty (creation of a vagina) and phalloplasty (creation of a penis), are known in the trans community as bottom surgeries.

Doctors in the field and trans people say there are only five Australian surgeons regularly performing these procedures.

Ms Clark's out-of-pocket surgery costs were $25,000, which would have been much higher had she not had private health insurance, which covered around $15,000 in hospital expenses.

Medicare contributed about $2,000 to the surgeon's fees.

"A lot of it's considered cosmetic. It's not, because in many cases, it is literally life-changing," Ms Clark said.

Now, for the first time, an application has been made to the commonwealth health department to list gender-affirming procedures on Medicare by the Australian Society of Plastic Surgeons.

Trans people, surgeons and advocates argue a better system of public funding for the surgeries could cut costs for patients and hospitals, as well as address availability concerns.

The president of the Australian Society of Plastic Surgeons, Nicola Dean, said the society made the Medicare application to the Department of Health as part of a collaborative effort with trans organisations and other health professionals to improve access to the surgery.

Dr Dean said this could incentivise more surgeons to join the field and provide better data on how many surgeries were taking place in Australia.

"A lot of it goes on a bit under the radar," she said.

"I think Australia is really quite behind other countries."

A Department of Health spokesperson confirmed it had received an application requesting the Medical Services Advisory Committee (MSAC) consider publicly funding gender-affirmation surgery and consultations under Medicare.

The department is currently considering if the request is suitable to be considered by MSAC.

A spokesperson said some Medicare rebates were already available "if the services are deemed by the treating practitioner to be clinically relevant to the care of their patient".

Surgeons have told the ABC the lack of specific Medicare item numbers for gender-affirming surgeries means costs are unpredictable and not transparent, and some procedures aren't covered.

In 2021, a petition to federal parliament for gender-affirming surgery to be included on Medicare gained nearly 150,000 signatures — the fifth most-signed petition on the Australian parliament website.

Clinical guidelines written by the Royal Children's Hospital Melbourne and endorsed by the Australian Professional Association for Trans Health (AusPATH) advise delaying genital surgery for trans people until adulthood. Surgeons spoken to by the ABC said they would only perform bottom surgeries for people over the age of 18.

Kieran Hart, a surgeon at ACT Urology in Canberra, said he had been swamped with requests for vaginoplasty and orchiectomy (removal of testicles) procedures.

In Dr Hart's first year in 2018, he performed three gender-affirming surgeries. Last year, he did 60.

He has about 150 people booked in for surgery, and 100 for consultations. His waiting list has only recently reopened.

"There's been hundreds who have been trying to get consults while I closed the books for a while," he said. A smiling man in scrubs in a hospital room.

The wait time is around two years, and about 90 per cent of his clients come from interstate.

He said private hospitals doing gender-affirming surgery "almost lose money" because the procedures were not listed on Medicare, meaning surgeons have to use different item numbers that don't quite line up with the procedure.

But Dr Hart said seeing the outcomes for trans women made it some of the most rewarding work a surgeon could do.

"It's just quite remarkable how resilient they are, but also what difference you make to their happiness and mental health," he said.

Advocates point to numerous studies which back the mental health benefits of gender-affirming surgeries for adults.

In a 2014 peer-reviewed study of 188 trans Australians, the 42.5 per cent of respondents who had undergone gender-affirming surgery reported higher levels of physical and mental health than those who had not had surgery. The difficulties in accessing surgery in Australia mean post-surgery survey sample sizes tend to be small.

A peer-reviewed analysis of the 2015 US Transgender Survey, which had 27,715 respondents, found the 13 per cent who had undergone gender-affirming surgeries in the preceding two years experienced a 42 per cent reduction in psychological distress and a 44 per cent reduction in suicidal ideation, compared to those who desired surgery but had not had it.

Not all trans people wish to undergo surgery, and for many of those who do, it is not financially viable — with nearly all surgeries taking place in the private system due to state government policy settings on elective surgery.

For trans men, getting a phalloplasty in Australia is even more difficult, with only two surgeons offering the procedure.

One is Brisbane-based Dr Hans Goossen, whose new patients might expect to wait six to 12 months for an initial consultation.

After completing surgical training in urology and reconstruction, he spent two years overseas learning the skills to do gender-affirming surgeries.

"It's still a relatively new field in Australia," he said.

"Until recently, most patients had to travel overseas."

Bottom surgeries for trans men include metoidioplasty and phalloplasty.

An insured patient might expect to pay $80,000 out-of-pocket, for what is a complicated and lengthy series of three or more operations. This includes costs associated with the surgery, anaesthetic, hospital stay, preparation and recovery.

"I understand people's frustration with the fact that it's currently not available in the public hospital system, and that it costs a lot of money and it's therefore not affordable for everyone," he said.

Dr Goossen wants to see federal or state governments fund a certain amount of surgeries per year, like in New Zealand, reducing the need for patients to spend tens of thousands of dollars on the procedures.

Another surgeon, David Caminer, started regularly performing phalloplasty and vaginoplasty procedures this year at his practices in Sydney and Wollongong.

Dr Caminer said even if the procedures ended up being listed on Medicare, patient costs would still be high due to Medicare not keeping up with inflation.

"The only way to get it cheaper, or for nothing, is to do it through the public hospitals," he said. Review announced into delivery of gender-affirming care in NSW following Four Corners investigation

A clinic at Westmead Children's Hospital has only seen three new patients this year and is struggling to operate in the wake of a string of staff resignations.

He said some private hospitals were religious, and did not permit gender-affirming surgeries to be performed or taught there.

"They won't allow you to do it, because it's not really keeping with their religious belief," he said.

After a religious hospital told Dr Caminer he could not perform a phalloplasty on a patient there, he's struggled to find another hospital with an intensive care unit to do the procedure. The patient has pre-existing health conditions so would require close monitoring.

"There's not that many intensive care units in the private sector," he said.

"It's taking me a lot of time and effort, we're still trying." Official training and support needed, surgeons say

To address the surgeon shortage, Dr Hart said the relevant medical societies and colleges could do more to introduce trainees to gender dysphoria theory and basic gender-affirming procedures.

"The College of Surgeons, we don't have a formalised training pathway for it at this point in time," he said.

"It's not really recognised in the curriculums for the Urological Society or the plastic surgeons' society."

A spokesperson the Royal Australasian College of Surgeons (RACS) said gender-affirming surgery was complex and required multidisciplinary consultation.

"While RACS supports the training of gender-affirmation surgery, it is important to note that the limited number of cases and the highly specialised nature of this field requires specific focus for a limited number of surgeons," they said.

Dr Dean from the Australian Society of Plastic Surgeons said in conjunction with RACS, her organisation provided plastic and reconstructive surgery training which was applicable to gender-affirming surgery, but there should be funding to send surgeons overseas to learn.

"We do have the basics of how to do the genital surgery, but it does need expertise to be built up," she said.

"And I think that it will take quite some time for people to learn off the few Australian surgeons that are doing this surgery."

About one in five patients access their superannuation to pay for surgery at Dr Hart's clinic, he said.

Sav Zwickl, a director with AusPATH, said this could put a financial strain on trans people.

"They spend years saving for surgery, and there's often no option but to access their super and, of course, that has long-term implications down the road for their financial situation," the researcher, who is trans and non-binary, said.

Dr Zwickl said many trans people went to Thailand for surgery, where surgeons were generally "very skilled and experienced in performing gender-affirming surgeries".

"That's a case of a lack of surgeons [in Australia], but also some procedures that people are looking for are not available in Australia at all," they said.

Anne* went to Thailand for her bottom surgery in 2012, after being quoted $30,000 for surgery in Australia.

"Surgery in Thailand was a lot more affordable than what it was in Australia," she said.

"Thailand has been performing these surgeries over there for thousands of trans women for decades."

To fund the surgery and overseas trip, she spent more than two years living in financial hardship.

Previously, Queenslanders wanting to change the sex on their birth certificates had to undergo gender reassignment surgery.

Without surgery, she wouldn't have been able to change her gender marker on her Queensland birth certificate, a requirement that only changed in June.

"I wanted to make sure that all my legal documentation was consistent," she said.

"Without having a birth certificate and official documentation, you're always having to explain yourself."

New South Wales and Western Australia are the only states still requiring gender diverse people to undergo medical procedures to update their birth certificate gender marker.

In WA, a "gender reassignment board" judges applications by trans people to change their gender, although the state is in the process of repealing these laws.

Surgery and the approval of a panel is required to legally change gender in NSW, but a spokesperson for the attorney-general said during the election campaign, Labor had committed to reviewing the legislation in consultation with trans and gender diverse communities.

The spokesperson said work had not yet started on reviewing the legislation.

Post surgery and legal recognition, life's a bit easier

Anne said she had no regrets about her decision to get surgery.

"It stopped the gender dysphoria, the thoughts of self-harm and suicide that I was experiencing," she said.

It's not lost on her that many trans people struggle to access surgery, but she's grateful to have a body she feels more at home in.

"I finally felt complete," Anne said.

Ms Clark can breathe a sigh of relief having overcome the hurdles of surgery.

"I've honestly never been happier, now that it's finally all sorted," she said.

"I occasionally catch places where I've forgotten to change my name, but by and large, it's so simple now."