The Wall Street Journal shares the news that gender affirmation surgery is becoming more available as more hospitals provide the procedure and more insurance comapanies provide coverage.

Some of the institutions offering the procedures are Cleveland Clinic, Boston Medical Center, Oregon Health and Science University (Portland), and Mount Sinai Hospital (New York City). Baltimore's John Hopkins Hospital, one of the first facilities to offer the procedures in the United States is "in the process" of reestablishing its program.

Previously, patients wanting transgender surgeries had to seek them out through private-practice plastic surgeons or in countries such as Thailand.

Full disclosure: the author had her surgeries performed by Dr. Eugene Schrang (now retired) at Theda Clark Regional Medical Center in Neenah Wisconsin in 1994 and 1995.

Demand is high, say doctors. Boston Medical Center, which opened its Center for Transgender Medicine and Surgery this year, began performing vaginoplasty, which creates a vagina, earlier in September. It currently has 200 people on a waiting list for the procedure, says Joshua Safer, the transgender center’s director.

There’s much greater buy-in [for transgender surgeries] in the conventional medical community than there ever was before.

--Dr. Safer

In 2014, the U.S. government’s Centers for Medicare and Medicaid Services began to allow coverage of transgender-related surgery. Currently, Medicaid programs in 12 states and the District of Columbia cover transition-related care, according to the National Center for Transgender Equality, in Washington, D.C. Many commercial insurers also have begun covering such procedures.

Centers performing vaginoplasty surgeries generally follow guidelines from the nonprofit World Professional Association for Transgender Health. The guidelines require that patients have letters from two medical professionals confirming a diagnosis of gender dysphoria, or feeling that patients’ identity is the opposite of their biological sex. They also must be on hormone therapy and living in their self-affirmed gender continuously for at least a year.

Squick alert:

In a vaginoplasty, parts of the penis and scrotum are used to create the vagina, clitoris and labia. Nerve endings are preserved to maintain sensation. The urethra is shortened to construct a female urethra.

I want to make sure they are happy and comfortable living as themselves full-time before I commit to doing an irreversible surgery.

--Dr. Cecile Unger, Cleveland Clinic

Vaginoplasty complications are rare but can include wound infection, excessive bleeding or injuries to the bladder or rectum. It takes about six to 12 weeks before the wound is healed and the reconstructed anatomy is functional, says Dr. Unger. Long-term healing can take up to a year.

Dr. Unger, who is 34, says she received training from a Philadelphia surgeon, who allowed her to assist in more than a dozen of the surgeries while she was completing a fellowship in pelvic reconstruction at Cleveland Clinic. She says she has performed vaginoplasty on five patients and is scheduling one to two surgeries a month. Her practice also includes doing reconstructions or revisions on patients who have had previous surgery. She and her team hope to begin offering transgender men phalloplasty surgeries, which create a penis and are a more complex and costly surgery.

A phalloplasty is usually performed in stages. First, the vagina is removed. The penis is constructed using tissue from another part of the body, such as the forearm or thigh. About a year later an implant may be inserted to allow for sexual functioning.

Jens Berli leads the plastic surgery component of the transgender health program at Oregon Health & Science University. He performs breast augmentation and facial feminization surgeries on transgender women. He and his team are scheduled to perform their first phalloplasty this week. A colleague, a urologist, began performing vaginoplasty surgeries there in May and currently has 180 patients on a waiting list, Dr. Berli says.

Phalloplasty surgeries are more complex than vaginoplasty and complications aren’t unusual. Most of the cost is increasingly covered by insurance and can range from $50,000 to $125,000, experts say.

One of the first fellowships in transgender surgeries will begin this fall at Weiss Memorial Hospital in Chicago, says Loren Schechter, medical director of the hospital’s Center for Gender Confirmation Surgery, who has been doing the surgeries for nearly 17 years.

The patient population is very, very grateful. To change somebody’s life in a few hours is really rewarding.

--Dr. Rachel Bluebond-Langner, University of Maryland School of Medicine

Dr. Bluebond Langner ays she now works almost exclusively with transgender patients since insurers in the state began covering the surgeries over the past two years.