The female-to-male surge in gender-affirming surgery: a National Study from Türkiye, 2009-2025

Recent years have seen a substantial rise in gender dysphoria (GD) diagnoses and requests for gender-affirming surgery (GAS), accompanied by major demographic changes among individuals seeking surgical transition.1–4 Studies from Germany and international databases report eightfold to tenfold increases in F64-related diagnoses among adolescents and young adults between 2013-2022 and 2017-2021. Data from the Williams Institute further show that transgender and non-binary identification is most prevalent in the 18-24 age group, reaching 700/100 000 (0.7%) and decreasing with age. Parallel to this rise, GAS procedures have expanded markedly. In the United States, GAS frequency quadrupled between 2015 and 2020, increasing from 299 to 1029 per million adults.2 Masculinization procedures remain the majority, comprising 71% of all GAS interventions in a national cohort of 4491 individuals operated between 2015 and 2020. Türkiye represents a unique setting due to its mandatory legal framework requiring court approval before GAS. Under Article 40 of the Turkish Civil Code, individuals requesting legal sex reassignment must be at least 18 years old, unmarried, identify as transsexual, and obtain a health board report confirming the medical necessity of GAS. Because national health insurance covers GAS following court approval, the application process captures nearly all individuals intending to undergo surgical transition. Consequently, court applications constitute a rare population-level dataset with minimal sampling bias, making Türkiye one of the few countries where GAS demand can be assessed through mandatory national records rather than clinical referrals.