The provision of gender-affirming surgery (GAS) has a substantial history in Australia, some proud and some less so, but there is a trend underway to professionalise and improve service to a deserving but sometimes ignored segment of our community. Surgical care provided in excellent units overseas can provide a model for service delivery, but the specifics of the Australian situation will demand uniquely Australian responses.

Gender Surgery Amsterdam (the Amsterdam unit), led by Professor Mark-Bram Bouman, has published peer-reviewed papers for 40 years and serves as a model of how GAS can be done well. The team is extensive and broadly multidisciplinary, with collaboration between surgeons and other doctors and a very real contribution from nursing and allied health practitioners. Among the surgeons are urologists, ear, nose and throat specialists, and gynaecologists, but much of the leadership remains with the plastic surgeons including Professor Bouman. Like other GAS services, the Amsterdam unit has seen a rapid rise in demand and struggles to match capacity to demand.

The Gender Rounds is a hands-on, operative surgery course, run by the Amsterdam unit. The magnificent teaching facility allows for cadaver-based teaching in conditions closer to an operating theatre than a university anatomy department. In March 2023, a small number of Australians joined surgeons from Canada, Thailand, Belarus and a larger cohort from the United Kingdom (UK) for a course focused on phalloplasty and associated prosthesiology. The UK health department had funded the trip for around a dozen nurses, urologists and plastic surgeons as it sought to drive the establishment of two public phalloplasty services (interestingly both in London).

Far apart from the hands-on surgical education, numerous other lessons were available from the Amsterdam unit. They have a very strong focus on patient-focused care, on the ethics of GAS and on being truly transparent with patients about results and complications. Specifically, the unit observes, as others do, that the majority of complications in phalloplasty relate to the urethral extension and to the prostheses required for erection. Careful discussion with patients reveals that these features are important to some patients but less important to others. Not every transman sees voiding standing as the most important issue in his surgical journey. These insights allow lower risk operations to be planned for many patients and improve overall complication rates. Many Amsterdam phalloplasty patients will opt for no urethral extension and no artificial erection device (they will void seated through a perineal urethrostomy on the ventral side of the base of the penis).

Decision-making for gender-diverse people considering GAS can be complex and the provision of appropriate tools has been a priority of the Amsterdam unit. GenderAid1 is an online, browser-delivered, open-access tool that presents decisions and options along with a discussion of pros and cons to inform patients of their options. It is worth a look.

Further activity in Amsterdam included work on the production of a patient-reported outcome measure for GAS–the Gender-Q2–and contributions to the World Professional Association for Transgender Health (WPATH) guidelines.3

Closer to home the New Zealand Association of Plastic Surgeons chose to make GAS the major topic of their 2023 meeting in Queenstown. International speakers, Dr Marlon Buncamper and Professor Stan Monstrey, both from Gent Belgium, spoke on the topic of building a world class GAS service over many years. Their service is only slightly younger than the Amsterdam unit. The New Zealand meeting was also enriched by papers on the local experience of GAS, including frustrations with funding and the isolation of performing relatively esoteric surgery when most of your colleagues do not.

In Australia the provision of GAS is growing but from a base where service delivery has been patchy, unable to meet demand and expensive for patients. Travelling overseas for surgery remains the best option, or perhaps the least bad option, for many gender-diverse patients. Attempts to provide care that is world class are inhibited by several factors including inadequate training, uncertain levels of stakeholder commitment, shaky funding and inadequate resourcing.

Only a small proportion of Australian plastic surgeons would see GAS as a significant part of their practice and most received little or no exposure to GAS during training (This topic is not specifically included in the curriculum for plastic surgery trainees in Australia.) Addressing this requires acknowledging the problem, altering the curriculum and looking for training opportunities. Furthermore, encouraging fellowship work for Australian surgeons post training is likely to be the best way to bring overseas excellence home.

Funding for surgical procedures in Australia is governed in part by the Medicare Benefits Schedule but the schedule includes no codes specific to GAS. The Australian Society of Plastic Surgeons is currently sponsoring an application to address this.4 Success would help surgeons and, importantly, hospitals with additional funding for providing GAS.

Models of care for the provision of GAS in Australia have largely been informal, implied or non-existent. Moves to define access, services, expectations and responsibility more formally have resulted in the publication of a model of care document by the South Australia government5 and other jurisdictions are following. The Australian Society of Plastic Surgeons has recently produced a document setting out suggested design principles for gender-affirming surgery services and key elements of good services.6

Australian responses to the need for better surgical care for gender-diverse people are developing with impetus coming from patients and their advocates, governments and, sometimes, hospitals. It has never been more important for plastic surgeons to lead the development of better services to provide excellent care, improve access and meet legitimate community expectations.