Chest masculinization surgery, often called gender-affirming top surgery, is considered medically necessary for many transgender and nonbinary people experiencing chest dysphoria, the distress arising from a mismatch between chest anatomy and gender identity. The operation encompasses a range of techniques tailored to individual anatomy and goals, with double-incision mastectomy with free nipple grafting the most common approach. The evidence base supporting the procedure has grown considerably. Prospective studies using validated instruments have documented significant reductions in depression and anxiety alongside improvements in body image and psychosocial functioning six months after surgery. Long-term follow-up of 139 patients two or more years postoperative reported median satisfaction scores of 5 out of 5 and decisional regret scores of 0 out of 100, with no participants seeking reversal.

Population-level data reinforce these individual outcomes. An analysis of national insurance claims found significantly lower rates of antidepressant use, suicidal ideation and attempts, and substance misuse among people with gender incongruence who had undergone gender-affirming surgery. A secondary analysis of the 2015 U.S. Transgender Survey, which included 27,715 respondents, found that those who had surgery at least two years earlier had significantly lower odds of past-month psychological distress, past-year suicidal ideation, and past-year tobacco use compared with those who desired but had not yet received surgery. Critically, the analysis controlled for prior transition-related care such as counseling and hormone therapy, isolating the surgical contribution. In the 2022 U.S. Transgender Survey of 22,285 respondents, 97 percent of those who had received surgery reported greater life satisfaction afterward.

The policy backdrop to the Cincinnati study is essential to interpreting its results. Medicare reversed its exclusion of gender-affirming surgery in 2014, and in 2016 the U.S. Department of Health and Human Services implemented Section 1557 of the Affordable Care Act, expanding the definition of sex discrimination to include gender identity and thereby prohibiting insurance discrimination against gender-affirming care. Federal regulations now prohibit categorical exclusions of such care in health plans receiving federal funding, and as of 2024, twenty-four states and the District of Columbia have enacted laws or regulations barring blanket exclusions in private insurance. The volume of surgery reflects this shift: one analysis documented a 152-fold increase in gender-affirming surgeries between 2010 and 2018, with the steepest growth, 257 percent, occurring in the Midwest during the implementation period of Section 1557.

Against that backdrop, the Cincinnati team assembled its cohort using the ICD-10 diagnosis code for gender incongruence and extracted demographic, clinical, and insurance data from the electronic medical record. The 128 patients had a mean age of 26.9 years, and 79 percent identified as transgender men while 21 percent identified as nonbinary. Public insurance was the norm, covering 64 percent of patients, including 57 percent on Medicaid. The vast majority of consultations, 90 percent, occurred in 2019 or later, underscoring how rapidly demand grew in the second half of the study window. All procedures were performed by the same group of surgeons throughout, which the authors note strengthens the internal consistency of the wait-time analysis.

The insurance findings are nuanced. Overall, 27 patients, or 21 percent, received at least one denial of prior authorization, and two-thirds of those denials came from public insurers. Yet the likelihood of denial did not differ significantly between public and private coverage, at 21 percent versus 20 percent. Seventeen of the 27 denied patients were ultimately approved after resubmission, while eight did not proceed and were lost to follow-up. Nonbinary patients were significantly less likely than transgender men to experience a denial, 7 percent versus 24 percent, a difference the authors attribute in part to the fact that all nonbinary patients were engaged in psychiatric care, which may have strengthened the medical necessity documentation supporting their authorization requests.

Wait times emerged as the study’s most policy-sensitive metric. The mean interval from initial consultation to surgery was 249 days, or roughly 8.2 months, with a median of 208 days. Publicly insured patients waited an average of 259 days compared with 218 days for the privately insured, a 41-day difference that was not statistically significant. Consultation year, by contrast, was strongly associated with wait time, with the shortest waits, 186 days, recorded in 2022. Neither insurance type assessed year by year nor the duration of gender-affirming hormone therapy independently predicted how long patients waited. That last result carries practical weight: hormone therapy duration requirements embedded in insurer policies appear to do little to expedite care, suggesting that timely progression depends more on coordinated documentation from primary care and mental health clinicians and on surgeons willing to engage in the appeals process.

Surgical outcomes added a further layer of complexity. Among the 89 patients, or 70 percent of the cohort, who underwent surgery, mean tissue resected was 875.2 grams and postoperative complications occurred in 11 percent, including infections requiring antibiotics, hematomas or seromas requiring drainage, delayed wound healing, and nipple necrosis. No patient required a return to the operating room. Nonbinary patients had significantly greater mean tissue resected than transgender men, 1410.6 grams versus 742.9 grams, and more frequently opted for a no-nipple result. They also experienced a significantly higher rate of postoperative infection, 16 percent versus 1 percent, though rates of seroma, delayed healing, and revision surgery did not differ by gender identity. The authors suggest the larger resection volumes may have contributed to the infection difference and note that similar revision rates between groups imply comparable achievement of desired aesthetic outcomes.

The study’s limitations are acknowledged candidly. Spanning nearly a decade of overlapping legal and policy changes, the retrospective design cannot isolate the effect of any single reform, and the analysis was not powered for granular year-by-year comparisons. Records may have omitted contextual details, and institutional factors are difficult to disentangle from broader trends. The single-center setting in a region without state-level nondiscrimination protections limits generalizability, particularly given that an estimated 44 percent of the LGBTQ population lives in states lacking such safeguards. Nationally, disparities persist: 28 percent of 2022 U.S. Transgender Survey respondents reported avoiding medical care due to cost, and 35 percent of those assigned female at birth who sought chest surgery reported a denial in the past year, with Medicaid recipients disproportionately affected.

Even so, the core message stands out with unusual clarity for health services research. Access to chest masculinization surgery at this Midwestern center improved primarily along a temporal gradient that tracks federal policy change, not along the insurance fault line that so often divides American health care. The authors conclude that federal policy shifts were associated with meaningful improvements in access across insurance types, even in a region lacking state-level protections, while cautioning that access remains tightly linked to policy and increasingly vulnerable to reversal amid ongoing federal reconsideration of gender identity protections under Section 1557. As the legal landscape evolves, they argue, research in the regions most exposed to policy change will be critical to understanding how these dynamics shape access to medically necessary care for transgender and nonbinary adults.

Subject of Research: Trends in insurance coverage and surgical wait times for gender-affirming chest masculinization surgery among transgender and nonbinary adults in the United States

Article Title: A decade under review—trends in insurance coverage and wait times for chest masculinization surgery in the United States

Article References: A decade under review—trends in insurance coverage and wait times for chest masculinization surgery in the United States. (n.d.). https://doi.org/10.1186/s44452-026-00020-0

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00020-0

Keywords: chest masculinization surgery, gender-affirming care, insurance denials, prior authorization, Affordable Care Act, Section 1557, transgender health, nonbinary patients, wait times, health policy, Medicaid, plastic surgery

The significance of the research lies in the population it centers. Sexual and gender-diverse women in Canada, including those who identify as Two Spirit, lesbian, bisexual, queer, transgender, or otherwise outside cisgender and heterosexual norms, experience documented disparities in health outcomes. These disparities are driven in large part by barriers to accessing care that is both clinically appropriate and culturally affirming. When mainstream healthcare fails these patients, whether through discrimination, lack of provider knowledge, or inflexible service models, community organizations step into the void, delivering services that range from gender-affirming care navigation to mental health support and sexual and reproductive health education. Until now, the requirements for developing and supporting this health promotion capacity among community agencies have remained largely unexamined in the health services literature.

To fill that gap, the research team conducted a qualitative descriptive study built around virtual semi-structured interviews with ten community-based staff members drawn from six Canadian provinces. Participants were purposively recruited through 2SLGBTQ+ networks, social media, and community outreach, a strategy designed to capture the perspectives of those directly embedded in service delivery rather than institutional spokespersons. The cohort reflected the diversity of roles that sustain these organizations: five health promoters, two executive directors, one therapist, one nurse practitioner, and one program coordinator, working at various career stages. Data collection took place between August and October 2024 through Zoom interviews that were audio-recorded and transcribed verbatim.

The analytical approach was methodologically rigorous. The team used NVivo 15 software to support systematic coding of the transcripts and developed themes through an iterative, consensus-driven process consistent with inductive thematic analysis. The study followed the Standards for Reporting Qualitative Research, and ethical approval was granted by the Toronto Metropolitan University Research Ethics Board under reference 2023-472, with online electronic informed consent obtained from all participants prior to participation. This level of procedural transparency matters, because qualitative findings in a politically sensitive field are only as credible as the methods behind them, and this study anchors its conclusions in a clearly documented and reproducible analytic chain.

Three overarching themes emerged from the interviews. The first concerned participants’ experiences delivering care, and it revealed the breadth of services these organizations provide. Staff emphasized the importance of delivering essential health services that include gender-affirming care, mental health support, and sexual and reproductive health education, all framed within culturally and linguistically appropriate models. In practice, this means adapting materials and encounters to the identities, languages, and lived realities of the women they serve, rather than expecting patients to conform to standardized clinical scripts. The findings underscore that cultural and linguistic appropriateness is not an optional enhancement but a core precondition for these services to work at all.

The second theme mapped the structural architecture that makes such service delivery possible. Participants identified leadership development, inter-agency partnerships, and attention to the social determinants of health as crucial components of organizational capacity. In other words, community organizations do not operate as isolated islands of care. They depend on leaders who can shepherd teams through uncertainty, on formal and informal partnerships with other agencies that extend their reach, and on programs that address the housing, income, and social conditions that shape health long before anyone walks through a clinic door. This systems-level view challenges the common caricature of community organizations as makeshift substitutes for real healthcare and reframes them as integrated nodes in a wider health promotion network.

The third theme catalogued the barriers, and it is here that the study is most sobering. Participants described inadequate and unstable funding as a chronic condition that undermines planning, retention, and service continuity. They reported shortages of trained providers, a lack of formal integration with the broader healthcare system, information gaps, language barriers, long healthcare waitlists, and persistent discrimination against the population they serve. Each of these barriers interacts with the others: unstable funding worsens workforce shortages, weak integration leaves community staff without referral pathways into hospitals and specialized care, and discrimination at the system level drives demand back onto already overstretched community services. The result is a reinforcing loop in which the organizations doing the most for a marginalized population are structurally resourced to do the least.

Against that backdrop, participants did not simply vent frustration; they proposed concrete remedies. They recommended enhancing resources, expanding staffing, strengthening education and training, intensifying advocacy efforts, deepening research engagement, and pursuing inclusive policy development to support organizational capacity. These recommendations collectively constitute a capacity-building agenda. Education and training would professionalize the workforce and improve service quality. Advocacy and policy development would address the upstream legal and institutional conditions that perpetuate inequity. Research engagement would ensure that services evolve on the basis of evidence rather than crisis response. And sustainable resourcing would give organizations the predictability they need to retain skilled staff and plan multi-year programs.

The authors conclude that several key factors may strengthen the health promotion capacity of community-based agencies serving sexual and gender-diverse women, including sustainable funding, workforce development, education, and research infrastructure. Crucially, they caution that future research should examine the broader applicability and effectiveness of these findings across diverse contexts, and they call for prioritizing structural change, intersectional approaches, and community-led solutions. That emphasis on intersectionality is significant, because sexual and gender-diverse women are not a homogeneous group; experiences of care vary by race, language, geography, disability, and socioeconomic status, and capacity-building strategies that ignore those intersecting identities risk reproducing the very exclusions they aim to fix.

The study was funded by the Canadian Institutes for Health Research, received on 11 November 2025, was accepted on 11 September 2026, and published open access on 22 September 2026. Its arrival could not be more timely. As health systems worldwide confront workforce shortages and rising demand for affirming care, the Canadian evidence offers a transferable insight: community-based organizations are not peripheral charities but essential health infrastructure, and the healthcare system’s treatment of sexual and gender-diverse women will depend on whether governments and institutions choose to fund, train, and formally integrate them. The ten staff members interviewed for this study described, in effect, a parallel health system running on commitment and improvisation. Converting that commitment into durable capacity, the research makes clear, is a policy choice that remains to be made.

Subject of Research: Health promotion capacity building in community-based organizations serving sexual and gender-diverse women in Canada.

Article Title: Building health promotion capacity for sexual and gender-diverse women: insights from staff at community-based organizations in Canada

Article References: Building health promotion capacity for sexual and gender-diverse women: insights from staff at community-based organizations in Canada. (n.d.). https://doi.org/10.1186/s12913-026-15624-6

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15624-6

Keywords: 2SLGBTQ+ health, community-based health promotion, sexual and gender-diverse women, health equity, gender-affirming care, capacity building, qualitative research, health services research, social determinants of health, workforce development, Building, health

The work was led by Isabelle S. van der Meulen and Sabine E. Hannema of Amsterdam University Medical Center, together with colleagues spanning endocrinology, urology, psychology, sexology and gynaecology. This breadth of expertise was deliberate. The authors argue that questions about puberty suppression and sexuality cannot be answered from within a single discipline, because puberty itself is a phenomenon that unfolds simultaneously across the endocrine system, the developing brain, the genital organs and the psychosocial life of an adolescent. The recommendations were further shaped by input from a round table session held at the 2025 conference of the European Professional Association for Transgender Health (EPATH), which brought together clinical and community perspectives on how these conversations should be handled in practice.

At the physiological level, GnRH analogues work by suppressing the hypothalamus–pituitary–gonadal axis, the hormonal cascade that normally drives the physical transformations of puberty. By halting the release of gonadotropins, the medications pause the production of sex steroids and thereby interrupt the development of secondary sexual characteristics such as breast growth, voice deepening, genital development and changes in body composition and distribution. The rationale is to give adolescents with persistent gender incongruence time to explore their identity without the distress of unwanted, and in many cases irreversible, pubertal changes. When treatment is stopped, endogenous puberty resumes; when followed by gender-affirming hormone treatment, a puberty aligned with the adolescent’s gender identity is induced instead.

However, the same sex steroid hormones that drive physical pubertal changes also play roles in genital maturation, neural development and possibly in sexual response and pleasure. Androgens, for example, contribute to clitorophallus growth and penile tissue remodeling, while estrogens influence vaginal and vulvar development. Suppression of these hormones during a critical developmental window therefore raises legitimate biological questions about whether later genital sensitivity, sexual function or capacity for pleasure might be affected. The authors stress that the existing evidence base is too sparse to answer these questions definitively, and that this uncertainty is precisely why structured, evidence- and experience-based counselling is so important for adolescents and their families who are weighing these decisions.

The recommendations generated by the expert group centre on providing developmentally appropriate information about puberty, puberty suppression and sexual development. Clinicians are encouraged to explain, in language suited to the adolescent’s age and cognitive stage, how the hypothalamus–pituitary–gonadal axis works, what GnRH analogues do to it, and what is known and unknown about the consequences for sexual maturation. Importantly, the experts also highlight psychosocial dimensions of sexual development, including the effects of stigma and minority stress, which research in sexual minority populations has shown to be strongly linked to psychological well-being and, by extension, to sexual well-being. Counselling that ignores these social realities, the authors suggest, would present an incomplete picture of what shapes a young person’s sexual development.

Another core recommendation concerns individualized decision making around fertility and future surgical options. Puberty suppression at early pubertal stages limits the development of gametes, complicating options for fertility preservation, and it also affects the tissues available for later gender-affirming genital surgery, such as vaginoplasty. Decisions about when to start suppression, whether to pause treatment to allow sperm or oocyte maturation, and how to counsel about surgical implications must therefore be tailored to each adolescent’s circumstances, values and goals. The experts emphasize shared decision making, in which adolescents, families and clinicians weigh benefits, risks and uncertainties together, supported by decision aids and ethics support tools that have been developed and evaluated in recent years within transgender care.

Equally central is the promotion of positive, open communication about sexuality itself. The authors note that sexuality remains a taboo topic in many clinical settings, including youth mental health care, and that transgender adolescents frequently report wanting their healthcare providers to talk with them about sexuality and gender diversity rather than avoiding the subject. The recommendations call for clinicians to proactively address sexual desire, arousal, pleasure, relationships and masturbation as normal components of adolescent development, rather than treating sexuality purely as a domain of risk or dysfunction. Tools designed to open these conversations with young people, including question-based conversational aids developed for gender-diverse youth, are highlighted as practical resources that can help clinicians overcome their own hesitation and make these discussions routine rather than exceptional.

On the research side, the article identifies major knowledge gaps and sets out priorities for filling them. Longitudinal studies following TGD individuals from the start of puberty suppression well into adulthood are needed, ideally combining quantitative measures with qualitative approaches that capture lived experience. The first exploratory studies in this area have offered a measure of reassurance: they found similar sexual well-being in young adults who received puberty suppression during adolescence and those who received gender-affirming hormone treatment without prior suppression. Research on sexual functioning after vaginoplasty, and on the influence of puberty suppression timing on later sexual function, has begun to map this terrain, but the authors caution that these are early, often small studies that cannot yet support firm causal conclusions. Research frameworks adapted from other fields, such as the target trial framework for observational data, may help strengthen causal inference in this challenging population.

A further priority is the development of TGD-specific instruments to assess sexual development, sexual function and sexual satisfaction. The authors argue that existing sexual health measures, which were largely designed for cisgender populations, fail to capture the diversity and intersectionality of sexual experiences among TGD individuals, including the interplay of gender dysphoria and gender euphoria with desire, pleasure and body satisfaction. Without valid, sensitive measurement tools, the field cannot accurately track outcomes or evaluate whether and how puberty suppression affects sexual well-being over the life course. Genital sensitivity itself, including erogenous sensation in surgically constructed and hormone-influenced genital tissue, is named as an area requiring both psychophysical and patient-reported investigation.

Ultimately, the expert recommendation is framed not as a verdict on puberty suppression but as a framework for honest, compassionate and scientifically grounded care. By integrating evidence where it exists, transparently acknowledging uncertainty where it does not, and centering the voices and experiences of TGD adolescents themselves, the authors aim to support individuals considering puberty suppression, their families and their clinicians in optimizing both care and long-term well-being. The call for longitudinal, interdisciplinary research signals that the scientific conversation is far from over, and that the coming decade of work will be critical in transforming clinical experience into rigorous evidence about how best to support the sexual development and sexual well-being of transgender and gender-diverse young people.

The biological rationale for caution rests on well-established endocrine principles. Sex steroids act not only as activators of sexual response but also as organizers of tissue development during defined windows of maturation, a concept long recognized in classical studies of pubertal staging in boys and girls. Analogies can also be drawn from conditions such as congenital hypogonadotropic hypogonadism, in which individuals experience absent or delayed endogenous puberty and require hormonal induction; research in these populations has examined psychosexual development under long-term treatment and offers a useful comparative lens for understanding how pubertal hormone exposure relates to later sexual function.

The clinical context for these recommendations has been shaped by several prior expert documents. The European Society for Sexual Medicine has issued position statements addressing hormonal management and sexual function in adolescent and adult trans people, as well as sexual well-being after gender-affirming surgery, and a working group of the European Society for Paediatric Endocrinology has published expert opinion on the endocrine management of transgender and gender-diverse adolescents. The new recommendation complements these efforts by focusing specifically on the intersection of puberty suppression and sexuality, an area those documents addressed only briefly.

Conceptual framing also matters. The World Health Organization defines sexuality broadly, encompassing sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction, and the ICD-11 now classifies gender incongruence outside mental and behavioural disorders. Within this framing, sexual well-being is understood as a positive dimension of health rather than merely the absence of dysfunction, which reinforces the authors’ argument that counselling should address pleasure and satisfaction, not only risk.

The evidence base itself has grown out of decades of longitudinal cohort research, most notably the Amsterdam Cohort of Gender Dysphoria, which has documented diagnostic and treatment trajectories since the earliest days of the Dutch protocol. Recent pilot studies from this tradition have begun comparing sexual function in adults treated with gender-affirming hormones with or without prior pubertal suppression, and examining sexual satisfaction following vaginoplasty in relation to the timing of suppression. Although preliminary, these studies represent the first direct empirical tests of questions that were previously addressed only through theory, and they provide the methodological foundation on which the recommended larger, longitudinal and mixed-methods research programme can now be built.

Subject of Research: The effects of puberty suppression with GnRH analogues on sexual development and sexual well-being in transgender and gender-diverse adolescents

Article Title: Puberty suppression and sexual well-being in transgender and gender-diverse individuals: evidence- and experience-based counselling and future research directions

Article References: van der Meulen, I. S., van den Boogaard, E., Özer, M., Bungener, S. L., Vrouenraets, L. J., & Hannema, S. E. (2026). Puberty suppression and sexual well-being in transgender and gender-diverse individuals: evidence- and experience-based counselling and future research directions. Nature Reviews Urology. https://doi.org/10.1038/s41585-026-01182-3

Image Credits: AI Generated

DOI: 10.1038/s41585-026-01182-3

Keywords: puberty suppression, GnRH analogues, transgender health, gender-diverse adolescents, sexual well-being, sexual development, fertility preservation, shared decision making, gender-affirming care, EPATH, Nature Reviews Urology, expert recommendation