August 28, 2023 - 10:00am

Last week, the New York Times reported that gender surgeries almost tripled between 2016 and 2019. That includes over 27,000 operations to amputate or simulate breasts, over 16,000 genital surgeries, and over 6,000 facial surgeries. Almost 8% of patients undergoing gender surgeries were 18 or under. 

These numbers, researchers point out, are almost certainly an undercount. 

The World Professional Association for Transgender Health’s latest standards of care lists 54 potentially “gender-affirming” operations patients might undergo — from hairline advancement to upper lip shortening to calf implants. Brow lines and jaw lines can be reduced or augmented. Nipples can be kept or removed. The penis can stay but a neovagina, lined with colon tissue, can be added. Patients can even opt to cut everything off and be as smooth and unreal as a Ken doll. 

Since such cosmetic interventions can only imitate the appearance of the opposite sex, that means there’s no end to the procedures patients and their unscrupulous surgeons can pursue. Sure, you’ll never become, but you can always keep trying! 

This is where gender dysphoria starts to look a lot like body dysmorphia. Address one “problem area”, and the dysphoria doesn’t resolve: it migrates. Patients and surgeons end up playing a macabre game of whack-a-mole. As dysphoria migrates across the body, new markets for surgical intervention open up. And because surgery will never turn a male into a female or a female into a male, the market for body modification is bottomless. 

Plastic surgeons are meant to screen out patients who have impossible expectations for cosmetic interventions. But take away the impossible expectations and transition falls apart. 

Some of these surgeries have horrifying complication rates, like phalloplasties. But medical complications can be reframed as opportunities, too. When Vanderbilt University’s Clinic for Transgender Health opened its doors in 2018, one physician pointed out: “Female-to-male bottom surgeries… these are huge money-makers.” 

As the number of detransitioners and regretters rise, “gender-affirming” clinicians must improvise to protect their revenue streams. They wax lyrical about “gender journeys” and shift to the slippery language of “embodiment goals”, which can always change. The target of surgical and hormonal interventions becomes whatever a patient desires today. The possibility that a patient’s desires may shift tomorrow — or curdle into regret — is no cause for concern. 

Last year two of the US’s leading gender clinicians, Johanna Olson-Kennedy and Jack Turban, contributed “dynamic desires for gender-affirming medical interventions” to the Newspeak dictionary. “Dynamic desires” means medical harm and regret. For Olson-Kennedy, the answer to surgical regret is more surgery. When asked about the possibility of regret and detransition, she mused: “What does that actually mean? Does that mean that someone has additional breast tissue that they would not want at a later point? But they could get that breast tissue removed if they absolutely need to.” Or maybe a patient had her breasts removed but “if you want breasts at a later point in your life, you can go and get them”.

This is an alarmingly casual attitude toward major elective surgeries. But it’s also a sign of the times. Everything is loosening and rolling downhill in one direction: toward ever more cosmetic interventions on healthy human bodies in the name of making the outside match the inside — whatever that means. 

Nonbinary patients — who might have avoided surgical interventions in favour of blue hair dye, personal “flair”, and interpersonal tediousness — chase an androgynous form that never existed in nature. There are even young people who shed their trans identities but insist on going through with “top surgery” or hysterectomies. 

In other words: it’s customise-your-meatsuit-o’clock. We’re normalising extreme body modification and the justifications (extreme distress, suicide prevention) are starting to fall away, replaced by a fatuous language of self-actualisation that hides its contempt for human limits under the whimsical dressings of gender play.

Eliza Mondegreen is a graduate student in psychiatry and the author of Writing Behavior on Substack.