Most surgeries occurring between 2000–2011, the report finds, were for patients not covered by health insurance. Between 2000–2005, approximately half the transgender patients in the study paid out of pocket, with the percentage rising to 65 percent between 2006–2011. But between 2012–2014, the numbers ticked downward, with just 39 percent having to pay out of pocket. According to the study's authors, a lot of that decrease is thanks to Medicare and Medicaid; in May of 2014, Medicare ended its 33-year ban on transgender surgeries.

Says the report, “Virtually every major medical association in the United States has described transition-related surgeries as 'medically necessary' for both the physical and mental health of transgender people. They also have stipulated that health insurance coverage for such operations should be no less available than it is for other types of surgery.”

Coverage for transgender surgery has been increasing in the U.S., not just in Medicare/Medicaid but also in state-sponsored private plans and employment insurance.

“These changes are driven by a growing expert consensus on the medical necessity of gender transition, new legal interpretations prohibiting insurance discrimination against transgender people, and mounting evidence that transgender-inclusive coverage is cost-effective,” writes Kellan Baker, of the Johns Hopkins Bloomberg School of Public Health, in the New England Journal of Medicine in 2017.

While few studies exist in the U.S. on the outcomes of transgender surgery, Europe has taken the lead, with more and larger studies conducted on the results. A study published in 2014 in the German Medical Association's official bilingual science journal Deutsches Arzteblatt found that 90.2 percent of 119 transgender women said that “their expectations for life as a woman were fulfilled postoperatively.”

And while Section 1557 of the Affordable Care Act barred discrimination on the basis of gender identity and helped ensure that more transgender men and women would be covered for surgical procedures, including genital reconstruction, it's by no means assured that that provision will continue to be honored under the Trump administration.

“There's going to be rough sailing ahead,” plastic surgeon Loren Schechter, who specializes in transgender surgeries, is quoted saying. Schecter adds, “There is concern in the community and among providers that many of the gains already made are in jeopardy.”