Europe’s Gender Surgery Market is Booming

Roísín Michaux on trans medical tourism and the unscrupulous monied interests driving private gender clinics

The same cities come up repeatedly in online support groups: Warsaw, Thessaloniki, Vilnius, Madrid. So do the names of the clinics: the cheap one in Lithuania, the big one in Belgium, the many, many options in Germany (but especially the one with the short wait times in Düsseldorf).

The names of individual surgeons, as well as ‘affirming’ psychotherapists, endocrinologists and GPs, are also passed around: they are in Liège and Anderlecht. Lyon and Lille. Galway and Drogheda.

People from countries with strict rules, high costs, and/or long waiting lists for transgender healthcare take Ryanair flights to countries that offer better deals. They fly from Helsinki to Berlin, Dublin to Madrid, Edinburgh to Athens. The decision as to which surgeon to “go with” is a question of trade-offs: one surgeon might be more expensive, but he goes by ‘informed consent’ (no diagnosis or referrals needed). Another might be cheap, but she doesn’t do ‘non-binary’ surgeries (meaning you may have to keep your hated nipples).

Individual surgeons and clinics all around the EU are operating in parallel to their country’s national gender service, if one exists at all, and they are inventing their own set of criteria for ‘care’ that can vary from cautious to criminally lax. National systems are usually located in public hospitals, often in multidisciplinary gender identity units, and they have rules about who is ‘truly trans’. These state-sanctioned services provide the public with the psychological assurance that somebody is regulating access to irreversible interventions for very distressed people.

But many (if not most) of the people on the waiting lists for ‘official’ assessment in various countries are on another, much shorter list for private treatment elsewhere. And it’s not just surgery: the same goes for cross-sex hormone treatments, puberty blockers, facial feminisation and voice training.

There is a growing number of chic surgical centres that are ethically freelancing, deciding what kind of trans-affirming interventions they will perform, under what conditions, and from what age. The only barrier to access is the price.

The Paper Trail

Some of these clinics and surgeons require a gender dysphoria diagnosis, while others will accept a letter from a GP simply claiming the patient is ‘seeking’ gender-affirming care (not that the patient is actually getting it). One clinic will accept a letter simply stating that the patient is distressed about their gender (don’t panic about the contents of the letter – strangers on social media will tell you exactly what it needs to say).

Another clinic partners with preferred mental health professionals, who know very well what the referral letter needs to have in it. That, too, can be built into the customer quote. This is a clever system because it creates the perfect paper trail – though it is designed with future legal liability in mind, not the wellbeing of the patient (many of whom start organising their surgeries long before they turn 18).

Some clinics skip the ethical theatre altogether, requiring nothing beyond your signature and a bank transfer. If you’re under 18, a parent’s signature is enough in Spain, Germany and Malta (that I can personally attest to). The same is likely the case in other countries.

Apart from paperwork, the practitioners also make up their own criteria regarding your physical state. As the market grows, competition grows with it, and prerequisites for qualifying for ‘care’ are abandoned. Being obese no longer matters to some surgeons. Certain practitioners require very little time spent on testosterone (or no time at all), while others don’t care if you’re a heavy smoker (or they don’t ask). Meanwhile, the list of comorbidities and medications that could be disqualifying shrinks. Being severely mentally ill does not seem to be an issue. After all, nobody wants to examine your mental health history to augment your breasts – why should it be an issue for removing them?

Whether these doctors think you’re really ‘trans’ or not doesn’t seem to matter.

Where no explicit legal minimum age limit exists, treatment decisions are based on individual doctors’ personal scruples, and his or her appetite for weathering potential future legal action. Countries whose authorities allow transition for minors use language like ‘in exceptional cases’, without specifying what the accepted exceptions are.

With such vague language, the market fills the gap, and it likely won’t be long before the legal cases begin to appear. Perhaps the surgeons have an escape plan lined up. But for now, as long as they don’t fall afoul of explicit national laws or guidelines, which, again, in some places either don’t exist, or which are covered in general medical ethics rules that are too unspecific to be actionable, practitioners follow their own ethical instincts.

Doctor Shopping Online

Communities gather on Facebook, Reddit and Discord to doctor-shop. Prices, attitudes to trans people, public transport availability, and reviews of Airbnbs in the neighbourhood are sought. Some post-ops write long essays detailing every moment, from the first email to the clinic, to the 3-months ‘after’ pictures, their feelings about the state of their scarring, and all the gory and logistical details in between. The shoppers lap it up.

Technical terms are part of the lingo: double-incision, perioral, batwing, donut. From drains to the dreaded ‘dog ears’. Nipples fall off, scabs get picked off too early, scars turn permanently red because they were cut in places where skin creases, because they were not massaged enough, or because the patient was too impatient and started back lifting weights too soon. Don’t make the same mistakes I did, they tell each other, but scarring, of course, is not always unwelcome; being visibly ‘trans’ at the beach in the summer is often the goal.

Don’t do anything for a few weeks after the surgery, pre-ops are warned. But few seem to be able to follow the aftercare advice. There is barely any follow up from the clinic; for many, getting their wounds checked would involve taking a flight (though one entrepreneurial clinic now offers an optional extra of aftercare – for a price – to its many patients in the UK and Ireland).

There is an understanding – whether it comes before, during or after the intervention itself – that paying for a procedure and getting reimbursed for it is the patient’s problem alone. Some seekers find out too late that meeting the clinic’s requirements doesn’t mean your public insurance (or even a very good private insurance policy) will cover your costs. This is particularly true when people opt for private surgery in their own country, all while assuming that the public health insurance scheme will cover their costs simply because their country has legal self-ID. So eager are they to get the procedure over and done with that getting their money back is often a marginal concern. And the clinics don’t dwell too much on the financial consequences during their perfunctory consultations over WhatsApp and Zoom (if they even offer that).

However, in one online community, I witnessed one member explain to others how her doctor gave her tips on circumventing the public insurance criteria. The surgeon had instructed her to provide the authorities with an insurance code that referred to scar repair (as opposed to mastectomy). In another case, a young woman found an ideologically-aligned rep working in the mutual insurance fund, who kindly went to bat for her internally, and managed to recoup some money on her behalf.

The Veneer of Accountability

This grey market exists wholly apart from discussions about public authorities’ decisions around gender-affirming care. It never seems to come up in media conversations about the availability and coverage of such interventions. It’s a topic that editors don’t seem to have the heart to touch.

The visibility of breastless females and men with chest implants (or no genital bulges, or shaved-down tracheas) might give the impression that she or he has been thoroughly assessed by professionals, and has been found, deep down, to be ‘truly’ transgender. But that’s probably relatively rare. In online communities, it is far more common to read testimonies of people who had their gender affirmed surgically and hormonally despite the public system in their home countries, not because of it.

Transgender surgeries are simply being absorbed like any other innovation into the plastic surgery market, all while the public assumes a robust system of checks and balances is whirring in the background.

Italy is a good example of the contrast in action: officially, a judge decides who gets to medically transition, a situation that has long been deplored by activists. But that acts as a smokescreen that gives NGOs something to rail against. In reality, anything is possible once you have money and the name of a willing medical professional. As the trans phenomenon in its current iteration is largely an upper middle-class social contagion, the most susceptible cohort is also the most likely to have the means to transition without any evaluation.

The truth is that fights over trans care are really just fights over public insurance coverage. The industry is booming.

Men Who Want Breasts

To illustrate just how far-removed the reality of trans healthcare is from the common assumptions about the regulatory framework, here’s a disturbing example: in researching communities of trans treatment-seekers, I came across a group dedicated to men who simply wish to have breasts. They don’t claim to be trans, or dysphoric, nor do they wish to be women – they simply want tits to play with. The bigger the better, is the general consensus.

One man says he had breast implants in the well-known Belgian clinic, the one shared often in trans communities. The man didn’t claim to be trans at all. Another bearded man from the UK was impressed by the size of his implants and asked for the name of the Belgian surgeon. “I promised not to say his name because of the extreme size I went. So sorry!” he replied. Indeed, another man advised, speaking of the Belgian clinic, “don’t expect to find info about super-large sizes on their website.” The man who originally asked the question ended up going to the Lithuanian clinic and posted his results all over social media.

No dysphoria, no gatekeeping, no checks. No trans, even. These are the same clinics where many British and Irish people get their operations. (Thankfully, both of these clinics told me they refuse to take minors.)

In the past, the job of gender shrinks was to screen out the fetishists, and to make sure only the truly trans (usually very femme-presenting gay men) were cleared for transition. Getting rid of gatekeeping for everyone got rid of gatekeeping for the fetishists, too.

From the Public Purse

There is an EU law that allows citizens to go abroad for treatment and to be reimbursed for it, under certain conditions: the same treatment must not be available at home (or not available within a reasonable timeframe) and it must be considered “medically necessary”.

Ireland’s treatment abroad scheme (TAS), as reported by Paddy O’Gorman on this website recently, was called into service to the value of over €330,000 in 2024 alone. What, exactly, the Irish public health system is reimbursing, and for whom, is not clear. A cheap mastectomy in the EU is about €3,000, with none of the frills. At the higher end, it can go up to about €10k all-in. More complicated surgeries, like vaginoplasty and metoidioplasty, can run into the tens of thousands.

The Dangers

Criticism of the various surgeons and their techniques in online fora is not always welcome, but particularly when it concerns services that are very cheap and easily accessible. The options are so limited that the precious few doctors must be protected at all costs.

The most dependable plastic surgeon in the Belgian word-of-mouth list for women seeking mastectomies, a man who operates in a number of locations in the south of the country, is alleged to have acted sexually inappropriately towards a woman as she sat in the examining table. He complimented her breasts in a creepy way, she told a French-speaking FtM (female to male) support group, and she just wanted them to know about it. Unfortunately for her, the moderator of the Facebook group had herself been operated on by the same surgeon and would not brook any criticism. The response to the woman’s allegation was ferocious, as the other members of the forum moved quickly to protect the integrity of ‘their’ surgeon, and thus their ‘access to care’. It was made clear that one person’s experience would not be permitted to jeopardise access to such a precious resource. The woman left the group and her posts were deleted.

On Facebook, a Scottish woman recounted that the clinic she went to didn’t notice that she had developed an infection, leading her to develop sepsis a couple of weeks later. Back at home, she almost died. The clinic denied her accusations of negligence. The last she heard from the clinic, she claimed, was as she was being readied for surgery to save her life. The clinic didn’t even try to find out if she was dead, she says.

But despite this, and other similar anecdotes, the surgeon is as popular as ever.

Dr Jesús Lago

There’s one name that comes up over and over again online: Dr Jesús Lago in Madrid. He’s so popular that there is a Facebook group dedicated to him. The moderator of that group is based in Ireland. The ‘Dr Jesús Lago’s Disciples’ community has nearly 900 members.

I contacted the Instituto Jesús Lago clinic in April, and I told the clinic worker that “my son”, a deeply depressed autistic girl of 15 years of age, who is taking medications of depression and other illnesses, desperately wants her breasts removed.

We discussed it over WhatsApp, and she quickly set up a call. I told her that both the girl’s father and I agree to the operation, and that I can provide a letter from a psychiatrist attesting to her gender dysphoria. The woman told me that both parents would have to be present in person in Madrid, the day before the operation, to sign the consent forms. No problem, I said. Could she have her vagina removed and sewn shut too? No, that has to wait until she is 18, I was told, as that was not reversible.

After a few days, I was offered an appointment for October and asked to confirm by paying a deposit.

I wrote back to say that there was an issue: unfortunately, in the end, my son’s father won’t make it to Madrid to sign the consent form. Also, the psychiatrist is now refusing to provide the letter. The woman called me and expressed frustration with the imaginary psychiatrist. But in the end, the clinic agreed to carry out the surgery. They are currently waiting for my deposit to arrive in their bank account.

Transition as a Human Right

There have been some worrying recent legal developments: four people took the French regional and state insurance funds to court because they refused to cover the costs of their medical transition procedures, and on 29 April, the judge ruled in their favour. This is the latest in a number of similar strategic cases supported by activists around France. The claimants in this case – one of whom was a minor when the ‘transition’ took place – convinced the judge that it constituted unequal treatment to reimburse surgeries related to cancer, but to refuse to reimburse the cost of the same operation carried out on the basis of being ‘trans’.

The judge cited the European Convention on Human Rights in the judgement, claiming it was a breach of one’s private life to require trans people to undergo onerous evaluations in the transition process.

One way to approach the trans medical phenomenon is to view it like any other aesthetic intervention: open to adults, who assume the consequences and the cost, without requiring anyone else to enforce their own self-perception as having changed sex. But mandating state insurance to recognise ‘trans’ as a human brain state, made real by mere declaration and affirmed by a selection of expensive medical interventions – and making this affirmation the responsibility of the public – is a very different proposition.

Since I started researching these groups a few years ago, the number of new names of surgeons, clinics and other doctors has exploded in online communities. Once these services are established, there is a lot of (monied) vested interest in keeping them running. It might even be easier to return public institutions to sanity than it is to wean the medical tourism market off a lucrative new revenue stream.

Róisín Michaux is an Irish journalist, writer, and podcast host based in Brussels who focusses on gender ideology, human rights, and European Union institutions. She is best known for authoring the Peaked newsletter on Substack and hosting the accompanying podcast. She is on X at @RoisinMichaux. Since 2022, she has observed the above in trans support groups, both public and private, in Belgium, Ireland, France, Germany and the Netherlands.

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