Fear being rejected: Half pay for gender-affirming surgery themselves

One third of those who had started hormone treatment, and half of those who had undergone gender-affirming surgery, paid for the entire treatment themselves.

This is shown by a new survey involving 579 trans and non-binary individuals from across Norway.

“Even though publicly funded treatment is available, many still choose to pay for care themselves. It’s striking, especially given that the participants were largely young people with low incomes,” says Silje-Håvard Bolstad, a researcher at the University of Agder's Department of Psychosocial Health.

At the same time, the survey shows that many of those with unmet needs for treatment could not afford to pay for it privately. For hormone treatment, this applied to around 46 per cent, and for surgery about 66 per cent.

Long waiting times and fear of being turned down

In Norway, publicly funded gender-affirming medical treatment is available at Oslo University Hospital.

The study did not specifically investigate why some people choose to seek treatment outside the public healthcare system, but Bolstad points to several possible explanations:

• Long waiting times
• Assessments that take at least one year
• Fear of being rejected after a lengthy assessment process
• Lack of knowledge about gender diversity within the healthcare system
• Non-binary people being denied treatment
• Lack of individually tailored treatment options

58 per cent of participants in the study had experienced discrimination within the healthcare system. This had happened either in connection with gender-affirming treatment or when seeking other forms of care.

“Some of those seeking gender-affirming treatment may have low trust in the public healthcare services, and therefore choose to pursue private treatment instead,” Bolstad says.

Satisfied with treatment

The survey also shows that the vast majority of those who have received treatment are satisfied with the results. This includes 93 per cent of those who received hormone treatment, and 96 per cent of those who underwent surgery.

35 per cent of trans men in the study had completed most of the gender-affirming changes they wanted. The share for trans women was 18 per cent, and 16 per cent for non-binary people assigned female at birth.

Among non-binary people assigned male at birth, none had completed most of the changes they wanted.

“Non-binary people may have different goals for their transition than what's typical among trans men and trans women. Some may not want extensive medical treatment, but instead prefer social changes or more moderate medical interventions,” the researcher explains.

Bolstad emphasises that trans people are a diverse group. 

“The findings highlight how important it is to tailor gender-affirming treatment to individual needs,” they say.

Many report mental health problems

Fewer than half of the participants (47 per cent) reported having good general health. In the general population the figure is 68 per cent.

“The survey aligns with much of what previous research has shown. The proportion experiencing mental health problems at a level requiring treatment was almost four times higher than in the general population. One in three has attempted suicide at some point in their lives, which is 12 times higher than what's found in studies of the general population,” says Bolstad.

Studies from many countries show that access to gender-affirming treatment can reduce mental health problems and prevent suicide among trans people.

“When we know that this group experiences significant mental health challenges, and that gender-affirming treatment leads to improvement, it's deeply concerning that they face so many barriers to accessing care, and that the public treatment services are so limited and difficult to reach,” Bolstad says.

Reference:

Bolstad et al. Gender-affirming health care needs, barriers to care, and health and wellbeing in a broad nationwide sample of transgender people in Norway, BMC Public Health, 2025. DOI: 10.1186/s12889-025-25243-1

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