Prevalence of and Factors Associated with Unmet Need for Gender-Affirming Surgery Among Transgender Women and Nonbinary Adults Assigned Male at Birth Receiving Hormone Therapy in South Korea

PURPOSE: This study assessed the prevalence of unmet needs for gender-affirming surgery (GAS) and associated socioeconomic factors among transgender women and nonbinary individuals assigned male at birth in South Korea. METHODS: A multicenter cross-sectional study was conducted using initial data from the Korean Initiative for Transgender Health study. It was conducted between January and October 2024 across eight medical institutions providing gender-affirming care in Korea. Transgender women and nonbinary individuals assigned male at birth (undergone or are currently undergoing hormone therapy) were included. Participants desiring but not undergoing GAS were classified as having unmet needs. Demographic and socioeconomic data were collected, and multivariable logistic regression identified factors associated with unmet needs. RESULTS: Among 540 participants (median age 27 years), 81.5% identified as transgender women and 18.5% as nonbinary individuals. Overall, 29.8% had undergone at least one GAS, whereas 90.6% reported unmet surgical needs. The most desired procedures were vulvoplasty with or without vaginoplasty (75.0%), orchiectomy (61.7%), and facial feminization surgery (61.3%). Financial burden (80.3%) and social discrimination (34.1%) were the most common barriers. Participants with diverse sexual orientations had higher odds of unmet needs for orchiectomy (adjusted odds ratio [aOR] 2.77, 95% confidence interval [CI] 1.67-4.60) and genital surgery (aOR 2.41, 95% CI 1.47-3.96) than heterosexual participants. CONCLUSIONS: Korea's National Health Insurance, covering the entire population, excludes GAS, forcing patients to pay out-of-pocket and causing high unmet needs. Financial barriers and social discrimination appear to substantially limit access, highlighting the need for structural efforts to improve access to GAS.