Women Speak Australia has responded to the Medical Services Advisory Committee (MSAC) consultation survey on Application 1754 — Surgical Procedures for Gender Affirmation in Adults with Gender Incongruence.
The application, made by the Australian Society of Plastic Surgeons, seeks the creation of new Medicare Benefits Schedule items for gender-affirming surgeries. MSAC describes these surgeries as a constellation of procedures intended to align a person’s body with their gender identity.
This consultation is specifically about the proposed Medicare funding arrangements. It is not a question of whether an adult may lawfully seek surgery.
The question before MSAC is different:
Is there sufficient evidence that these procedures are safe, effective and provide sufficient long-term benefit to justify funding them through Medicare?
Women Speak Australia does not consider that this threshold has yet been met.
What is MSAC considering?
Application 1754 covers a range of very different surgical procedures, including genital reconstruction, chest surgery, hysterectomy, facial surgery, tracheal surgery and voice surgery.
These are not one intervention. They involve different levels of complexity, different risks, different outcomes and different evidence bases.
WSA therefore considers that they should not automatically be assessed as one homogeneous category.
MSAC considered the clinical evidence for Application 1754 in April 2025. Its public summary identified significant uncertainty in the evidence and called for further work, including a more comprehensive assessment of comparative safety and effectiveness, further consideration of models of care, and evidence concerning the natural history of gender incongruence, regret and detransition, and outcomes for different populations.
That further work remains part of the current assessment. MSAC is scheduled to consider the application again on 26–27 November 2026.
WSA’s response argues that establishing Medicare items while important evidence gaps remain would be premature.
What did WSA tell MSAC?
Multidisciplinary assessment should be meaningful
WSA supports a robust multidisciplinary assessment process for Medicare-funded surgery.
However, we do not believe that one fixed combination of clinicians can appropriately assess every proposed operation.
A person considering complex genital reconstruction requires different expertise from someone considering a less extensive procedure. The appropriate team should therefore depend on the surgery being considered and the circumstances of the individual patient.
Potential members may include a GP, endocrinologist, psychiatrist or psychologist and the relevant surgeon, with a gynaecologist or urologist involved where appropriate. Other specialists may also be required depending on the procedure.
The important issue is not simply having a particular number of clinicians or professional titles.
The assessment should consider the patient’s medical and psychosocial circumstances, the specific procedure proposed, its degree of irreversibility, foreseeable complications, possible revision surgery, alternatives and whether the anticipated benefits justify the risks.
WSA therefore supports multidisciplinary assessment as a prerequisite for Medicare-funded surgery, while opposing a rigid one-size-fits-all model.
There is no reliable basis for assuming one “typical” pathway
The MSAC consultation asked respondents to identify surgical combinations that could be used as exemplars for different patient groups.
WSA answered “other” to these questions.
The consultation asks respondents to identify combinations used by more than 50 per cent of patients. In WSA’s view, this cannot responsibly be answered without reliable Australian utilisation data demonstrating how frequently particular combinations of procedures are actually undertaken.
This is particularly important for non-binary patients, where assuming a standard surgical pathway risks creating certainty that the evidence does not provide.
The different procedures should instead be assessed separately, or in clinically meaningful groups, according to their evidence, risks, benefits and long-term consequences.
What happens after surgery matters
One of the issues that needs greater attention is what happens after the initial operation.
Post-operative care can involve wound management, infection, urinary and other functional problems, pain, sexual and reproductive health issues, and further surgery or revision where complications occur.
For complex genital reconstruction, these issues may continue for years.
MSAC’s April 2025 public summary reported complication rates of 31.5–43.8 per cent for phalloplasty and 11.1–32.1 per cent for vaginoplasty in the studies it reviewed.
For phalloplasty, reported complications included infection, urethral stricture or fistula, partial loss, dehiscence and mechanical failure. MSAC also cited evidence of substantial revision requirements following phalloplasty with penile-prosthesis implantation.
These figures are not Australian Medicare outcomes and should not be interpreted as applying to every procedure. They do, however, demonstrate why an assessment of public funding needs to take account of complications and subsequent treatment rather than focusing only on the initial operation.
More recent research continues to highlight the difficulties in establishing reliable long-term outcomes.
A 2024 population-based study of phalloplasty in California found that, among patients who could be followed through record linkage, a substantial proportion subsequently returned to inpatient, emergency or ambulatory surgical care for phalloplasty-related complications. These included urinary symptoms, catheter problems, urinary tract infection, fistula, stricture and wound problems.
Importantly, a return-to-care rate should not be confused with a rate of major surgical failure. It nevertheless illustrates the potential continuing clinical burden associated with complex reconstructive surgery.
A 2026 systematic review of phalloplasty likewise identified substantial complication rates and noted that important outcomes, including urinary function, sensation and cosmetic outcomes, were inconsistently reported.
This matters for Medicare because the clinical consequences and resource requirements of an intervention do not necessarily end when the initial surgery is completed.
Satisfaction is not the same as comparative effectiveness
WSA considers it important to distinguish between a patient’s satisfaction with treatment and the evidence required to justify public funding.
Patient-reported satisfaction is an important outcome. However, satisfaction alone does not establish comparative clinical effectiveness, long-term benefit or whether an intervention provides sufficient value to justify public expenditure.
A Medicare assessment needs to consider the broader evidence.
This includes questions such as:
- What are the long-term outcomes?
- How does surgery compare with non-surgical care?
- Which patients are most likely to benefit?
- What are the complication and revision rates?
- What are the long-term functional outcomes?
- How do outcomes differ between procedures and patient populations?
- What is known about regret and detransition?
- What is the natural history of gender incongruence?
- What are the long-term healthcare requirements following surgery?
These are particularly important questions where some procedures are irreversible and may involve complex reconstruction and potentially long-term specialist follow-up.
Why WSA does not support Medicare funding at this stage
WSA supports the right of adults to make lawful decisions about their own medical care.
That does not mean that every lawful medical procedure should automatically be funded through Medicare.
Public funding requires evidence that the benefits of an intervention justify its risks, costs and opportunity costs.
In its response, WSA identified continuing uncertainty concerning:
- long-term outcomes;
- comparative effectiveness;
- complications and revision surgery;
- long-term functional outcomes;
- outcomes across different procedures;
- outcomes for different patient populations, including non-binary patients;
- regret and detransition;
- the natural history of gender incongruence;
- which patients are most likely to benefit; and
- outcomes associated with non-surgical or alternative approaches.
These are not simply concerns raised by WSA. MSAC itself identified important evidence gaps in its earlier assessment and requested further work.
For WSA, that is the central issue.
The question is not whether these operations can be performed. The question is whether the evidence is sufficiently robust to justify establishing publicly funded Medicare services for them.
WSA considers that the evidence threshold has not yet been demonstrated.
We therefore do not support Medicare funding for the proposed surgical procedures under Application 1754 at this stage.
Further evidence should be completed and properly assessed before a decision is made to establish Medicare items for these procedures.
WSA’s response to the consultation
The MSAC consultation survey was completed by Dr Elizabeth Caballero, President of Women Speak Australia, in her capacity as a retired general practitioner.
WSA has no financial, professional or personal interest in Application 1754. It does not provide the proposed procedures, is not the applicant and does not receive funding from the applicant or from providers of these procedures.
Further information
MSAC Application 1754:
https://www.msac.gov.au/applications/1754
MSAC consultation:
https://ohta-consultations.health.gov.au/ohta/1754-resubmission/
Read response to the MSAC consultation survey:
Note: This page reproduces Women Speak Australia’s response to the MSAC consultation survey on Application 1754. The response was submitted in October 2026. References and links are provided for the evidence cited by WSA. Minor formatting changes have been made for web publication.