The Ethical Intricacies of Transgender Surgery

A person on a blue and purple background with marking on their face

Illustration by Taimi Xu

Article by Leyla Giordano


Over the past decade, the transgender population has increased in visibility dramatically in the United States. The medical field has made progress when it comes to access to gender-affirming surgery; however, the progress has not rid society of discrimination and bias towards the transgender population, and access to care is still limited. Thus, it is essential to train medical professionals to care for this vulnerable population with compassion and knowledge. During the summer of 2018, I interned at the Gender Reassignment Department of Mount Sinai Hospital, where Dr. Jess Ting pioneered New York City’s first surgical program dedicated to transgender surgery. I learned that he transforms bodies every day in his operating room and cares for his patients with empathy, but he also struggles with feelings of helplessness when his patients share their devastating stories and disappointment when his surgeries are unable to live up to their expectations.

The American Psychiatric Association defines transgender as “a person whose sex assigned at birth (i.e. the sex assigned at birth, usually based on external genitalia) does not align with their gender identity (i.e., one’s psychological sense of their gender).” 1 Further, a subset of transgender individuals will experience gender dysphoria, defined by the American Psychiatric Association as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.”1 Thus, the dysphoria refers to the psychological distress that can often result from being transgender. In response to gender dysphoria, one may seek affirmations in several areas, including but not limited to social, legal, medical, or surgical. Medical and surgical affirmations are two ways in which one’s true identity can be revealed externally to society. Gender affirming surgery includes vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, and others.3 Surgeries like these can help reduce an individual’s gender dysphoria so that their physical body matches their gender identity.

Overall, transgender surgery improves lives because it gives trans individuals a body in which they feel more like themselves. However, the transgender population faces significant disparities in social determinants of health. These detrimental determinants limit Dr. Ting’s ability to heal this vulnerable population, frustrating him as he is ultimately unable to fix the discriminatory social context they encounter outside of the hospital. This paper will first discuss what it means to be transgender and how Dr. Ting’s work improves their life experiences. It will then move into the broader traumas that transgender individuals face. Finally, this paper will discuss the limitations and frustrations of Dr. Ting’s practice and how they have affected his approach.


Being transgender in our society and life-changing surgery

Since the 1900s, historians, activists, anthropologists, and many others have engaged in the debate between sex and gender. The social presentation and embodiment of one’s gender can differ from the anatomy or chromosomes with which one is born. Until recently, people have assumed that females act feminine because they have a uterus, not because they identify as a “female.” Society has assigned certain characteristics to what it means to be a girl, such as wanting to wear lipstick and play with Barbies. In the 1960s, a white and Western feminist theory emerged that posits that sex refers to the natural anatomical features, whereas gender refers to the culturally constructed norms that have been built based on one’s sex.2 This theory persisted into the 1990s, when Judith Butler argued that, in addition to gender, sex is also a social construct. She posited that if gender and sex are both social constructs, then these two terms are essentially the same.2

For decades, long-standing ideologies have informed beliefs that the trans identity is unacceptable since it runs contrary to the societally constructed connection between sex and gender. However, individuals like Dr. Jess Ting are contributing to the current shift in that dialogue surrounding the acceptance of trans identities. The Gender Reassignment Department that Dr. Jess Ting helped create at Mount Sinai Hospital gives transgender individuals the medical care that they need, changing the discourse around the transgender identity from taboo to celebrated. For example, in an interview I conducted with Dr. Ting, he recounted a memory about his oldest patient, who has stayed with him for five years. She was 77 years old and had been married to a man for many years. She told Dr. Ting that “this [surgery] is something I want to do for myself. I’ve wanted it since I was five years old, and I have never been able to get it.” As soon as Dr. Ting began to sign her up for surgery, she began to cry. She said, “I thought you were going to tell me that I was too old for surgery.” This story has stuck with Dr. Ting ever since because, as he says, “it’s powerful to give someone something that they have wanted for their whole life.” This patient had previously not gone to a doctor for the surgery out of fear that she herself and her identity would never be accepted. She also never had access to surgery because until 2016, no surgical programs existed in the state of New York. However, at the age of 77, the discussion around the transgender population has become significantly more welcoming and access to these operations increased such that Dr. Ting’s patient was able to finally get the gender-affirming surgery for herself.

A significant number of Dr. Ting’s operations are facial feminization surgeries. Facial feminization surgery, which includes shaving the male protruding forehead and brow ridge and softening the nose and jaw, are sought out by transgender individuals who identify as women and hope to have society externally view them as women. It is difficult to masculinize a face, but facial feminization surgery is extremely effective in giving a patient the stereotypical female features, such as a less-protruding forehead. Society consistently puts pressure on each gender to embody certain characteristics, as Eric Plemons points out in The Look of a Woman: “Yes, [the operating room] was the precise location in which patients’ longed-for physical transformations took place. But it was also a place whose material dynamics pushed and pulled at conceptual frameworks of embodiment and selfhood that lay at the heart of trans-body projects.”3 Dr. Ting revealed to me that the most common reaction he gets from his patients post-surgery is, “I just feel like me now,” as the material change in their appearance is an important part of what finally allows them to externally embody their ideal selves. Thus, the operating room becomes a place where the physical transformation makes it possible for a transgender individual to finally fit their own vision of themselves.

In a visual society such as ours, one’s facial features become the most salient factor in society’s recognition of one’s sex. As Plemons mentions, “Facial feminization surgery is guided by hope for future phenomenological integration and social recognition the creation of a body that (re)presents the self.”3 Transgender individuals are unable to embody their ideal selves when they remain in the body they were given at birth. However, through facial feminization surgery, a transgender female can be outwardly recognized as a woman, making gendered embodiment a social phenomenon. As Rosalind expresses in Plemons’ article, “‘I’ve spent twenty-five years of my life thinking about not looking like I do now. I want that to go away. Constant thinking about that ruins the mind. After this I’ll be able to think of other things, everyday things.’”3 Rosalind’s inability to embody her ideal self consumes her, as she is told every day by society that her gender identity is based off her recognizable characteristics like her Adam’s apple and her “Neanderthal brow.”3 Facial feminization surgery is, thus, a popular way to experience the world in a body that is outwardly recognizable and accepted as female.

The stereotypical facial features of a woman are what have been defined as “normal” to society. These features include a softer brow ridge and forehead, eyebrows with a slight arch, fuller lips, no facial hair, and a smaller nose. Society defines these characteristics as female, and it also defines a binary of female and male as the only acceptable genders. According to Abramowitz’s three definitions of “normal,”—socially accepted or morally condoned, statistically most common, and frequently occurring in everyday life—each society determines that a specific anomaly is not “normal.”4 Using these definitions, society sees transgender individuals as not “normal.” However, this is not how society should see the transgender population. This isolation is the exact disposition that leads to transphobia and a lack of transgender-specialized healthcare in the United States. Transgender individuals have reported that the most significant barrier to health care is the lack of physicians who are culturally competent and knowledgeable on the population.5 Dr. Ting echoed this shortage when he discussed his introduction into the field: “When we started our program in 2016, there was no place in New York City to access transgender surgery.” Despite the discrimination they face, transgender individuals are normal and should be considered normal by society; they are simply human beings who do not feel comfortable in their own bodies. Through his work at Mount Sinai Hospital, Dr. Ting became a pioneer in this field of medicine, making the transition to an embodiment of transgender individuals’ ideal selves possible.



The broader traumas

Trans individuals’ health outcomes are negatively impacted through several factors, such as intense stigma, increased harassment, and restricted access to employment, healthcare, and insurance. The detrimental effect that these factors cause can extend as far as suicide. Dr. Ting revealed, “The thing that was most impactful for me was when we first started seeing patients. One of the patients that I had interviewed and was going to schedule for surgery killed themselves. And up until that moment, I did not understand what the trans experience meant. That’s how I came to understand why these surgeries can be lifesaving.” Despite the beneficial impact of transgender surgery, it cannot rid the United States of its unequal structural and social determinants of health. Transgender individuals often have restricted access to employment, healthcare, and housing compared to cisgender individuals.6 Dr. Ting mentioned in our interview, “So many of my patients are sex workers, are undomiciled, and are living in shelters. This made me realize that I was judgmental. There’s not much that separates us from people who live on the streets or who are sex workers. When you have no other options, that is your only way of surviving.” The lack of these fundamental resources can lead to increased stress and poor physical and mental health, such as depression, suicidality, and chronic illnesses.6

The othering of the transgender population leads to an intense and detrimental stigma surrounding the trans identity. Transgender individuals experience structural stigma (societal norms), interpersonal stigma (verbal harassment, physical violence, sexual assault), and individual stigma (the feelings these individuals hold about themselves that may shape future behavior such as the anticipation of discrimination). Structural stigma originates from the socially constructed gender binary, and therefore marginalizes those that are considered “abnormal.” This stigma may “therefore operate as a form of symbolic violence in which structures, such as communities, institutions, or governments, […] restrict and forcibly reshape transgender individuals in ways that ultimately serve to maintain the power and privilege of the cisgender majority.”6 For example, a lack of insurance within the transgender population may lead trans individuals to pay out of pocket for procedures, which therefore makes it more likely that they feel they have no option other than to use cheaper street hormones acquired through friends or online.6 Secondly, interpersonal stigma refers to the increased levels of physical and sexual harassment:“It is theorized that gender nonconformity causes perpetrators of violence to become anxious and angry, ultimately enacting violence against transgender people as a means of rejecting and diminishing that which they fear.”6 Further, a national survey showed that, out of 402 transgender individuals, 47% had been assaulted and 14% of the 47% had been raped or survived attempted rape.7 Thus, transgender individuals experience disproportionate abuse in their lifetimes, whether that be in the form of hate crimes, sexual assault, or verbal abuse. Finally, individual stigma refers to transgender individuals’ negative image of themselves. This stigma makes them anxious to seek out healthcare and destroys their ability to deal with external stressors, leading to an increase in preventable deaths such as suicide.

Another crucial example of  negative health outcomes among the transgender population is the increased rate of HIV. According to the Journal of Virus Eradication, “transgender women have a pooled HIV prevalence of 19.1%, […] For transgender women sex workers, HIV prevalence is even greater, estimated at 27.3%.”8 Researchers believe that the increased risk is multifactorial and may be “due to differing psychosocial risk factors, poorer access to transgender-specific healthcare, a higher likelihood of using exogenous hormones or fillers without direct medical supervision, interactions between hormonal therapy and antiretroviral therapy, and direct effects of hormonal therapy on HIV acquisition and immune control.”8 The fear of the medical setting that is present in the transgender population could lead to decrease testing for sexually transmitted infections, and therefore higher rates of HIV. Additionally, the stigma that surrounds the trans population leads to an alarming amount of trans individuals going into sex work due to the absence of other employment opportunities, which could also lead to increased levels of HIV.

The aforementioned factors contribute to a symbolic violence in which transgender individuals internalize the social asymmetries they experience.9 This internalization can lead to a reactive personality and may even culminate in a personality disorder such as borderline personality disorder, since transgender individuals become used to the abuse and thus have learned to fight for themselves. As Dr. Ting reflected, “When anything goes wrong, [my patients’] reactions can be overwhelming and out of proportion to what you would expect. They blow up at me all the time. […] Trans people have a lived experience where […] they are subjected to abuse, and they are ignored. When you live like that, you build up your fences and you learn that you have to fight and scream for just regular occurrences.” Every day, Dr. Ting sees first-hand the internalization of the stigma that the transgender population faces. Trans individuals begin to view themselves and their self-worth through how they are negatively treated, prompting the development of a personality that is programmed to protect oneself against the world.


Limitations of Dr. Ting’s practice and their effects

The discrimination and abuse that Dr. Ting’s patients experience often exceed the medical realm, so an approach that focuses on narrative medicine and listening to his patients’ personal stories is important.10 In “Narrative Medicine: Attention, Representation, Affiliation,” Rita Charon moves past the narrow focus on her patients’ physical bodies and approaches her patients with a dedication to their stories.11 As Charon writes about a patient, “It was not just a matter of my having to know which section of his brain infarcted in his stroke but also what his stroke made of him, what it did to him, how he fought back from it, […] whether he will be the person he once was. It mattered to him and to our future clinical relationship that I know these things, that I have heard his fears and rage and grieving.”11 Similarly, Dr. Ting is committed to listening to his patients’ personal stories about their experiences as transgender individuals. In our interview, he emphasized how important it was to him to listen to his patients and their concerns, as his patients often lack a support system. In this way, similarly to Dr. Charon, Dr. Ting acts as an empathic witness for his suffering patients.10

However, physicians can only open themselves up to others’ suffering to a certain extent, and this balance has been difficult for Dr. Ting. When his patients come to his office, they have looked forward to their gender-affirming surgery for years, putting immense pressure on the outcome. This pressure can also lead to a dependency on the physician after a successful surgery for further help; however, Dr. Ting can only accept so much responsibility. During our interview, Dr. Ting reflected on a close relationship he built with one of his patients that caused him a large amount of grief: “One of my patients killed himself. He didn’t have a very smooth postoperative course. During Thanksgiving, he was texting me and meeting with a urologist. The urologist didn’t like the way that this patient was speaking to him. He can be a little rough, and the urologist [denied him care]. He then texted me saying, ‘What am I going to do now?’ I remember that I was out of town, and I responded ‘Don’t worry, we’ll find you someone else. It’s going to be okay.’ And he texted a few more times on Thursday or Friday, and then over the weekend, I noticed that I hadn’t heard from him in a while. I texted him on Monday to ask how he was doing, and I never heard back. A few days later, I found out that he had killed himself on the Monday after Thanksgiving.” With this news, Dr. Ting blamed himself, thinking that it was the complications from his surgery that made his patient commit suicide.

Physicians around the country experience burnout from job demands such as an overwhelming workload and emotional demands. Research on the mental health of psychologists and other physicians shows that these occupations aim to help people in need, leading to a high level of responsibility and increased emotional and interpersonal stressors for the physicians themselves.12 Dr. Ting could not help but assign blame to himself for his patient’s suicide. In the process of doing so, the high level of compassion and empathy required of him negatively affected Dr. Ting. For psychologists, emotional exhaustion is the most commonly reported cause of burnout.12 Although Dr. Ting is not a psychologist, his patients often depend on him for matters that extend past his office due to their lack of a support system. Dr. Ting provides life-changing surgeries to a very vulnerable population and deeply cares about his patients, and that type of work requires high levels of involvement, which can lead to burnout. As a consequence of burnout, research has shown that physicians then “seek an escape or distance themselves from their work both emotionally and cognitively, and [the burnout] is thought to lead on to feelings of cynicism.”12 Dr. Ting felt himself burning out from the emotional burden he experienced while forming close relationships with his patients, and it forced him to place distance between him and his patients.

Thus, especially after his patient’s suicide, Dr. Ting decided to set a boundary between him and his patients by strictly keeping his relationships to his office. It was necessary for Dr. Ting to adopt a medical gaze to take care of himself.13 In the process, he lamented the loss of the personal relationships he had built:

In the beginning, I would find myself getting very close to patients, sharing lots of details of their lives. In a way, that was really gratifying and rewarding for them to share emotionally fraught things. That’s why you become a healer. You want to heal people, and part of that is the positive feedback you get back from patients. Over time, I found that 99% of patients would be great, but the one complication would take so much out of me mentally. I could feel myself burning out a lot, so now, I am much more careful with patients in terms of creating boundaries. I don’t get as close to patients, which is sad, but it is necessary to protect myself. When I go see patients after surgery, and they tell me that I changed their lives, [saying] “How can I ever thank you?”, I feel like I have become a little numb to that, and I put up the boundaries where I’m afraid to let myself get close with patients.

Dr. Ting struggles between his commitment to his patients on a personal level and protecting himself from extreme responsibility for his patients’ distress. This complicated experience unfortunately limits the extent of his care. Despite the loss of many relationships that he values and his commitment to his patients past their physical bodies, Dr. Ting finds himself having to take a step back to separate himself from the burden of his patients’ trauma.

Overall, Dr. Ting changes his patients’ lives by giving them a body they can finally love and claim as their own. However, this responsibility brings a lot of pressure, as Dr. Ting expressed in our interview: “There is this tendency to idealize what’s going to happen or to feel like this surgery will cure everything – it will cure ‘all my ails.’ It doesn’t do that, it doesn’t cure all the ails of society – it makes your body align better with your internal identity, but you still have to go out into the world, and the world is not a better place.” Dr. Ting’s contributions to the transgender community supersede all expectations and grant so many the bodies and comfort they so desperately need, but he himself cannot change the society that transgender individuals enter back into when they leave the hospital. Despite the intense grief that Dr. Ting conveyed when he talked about the suicide of a patient and close friend, he ended our interview by relaying an encouraging conversation he had with his late patient’s partner: “She told me that the patient loved the body that I made for him, even with the complications. She told me that if he hadn’t had that surgery earlier, he would’ve died even sooner. He would not have even lived this long. For me, that lifted a heavy burden. I realized that maybe it wasn’t my fault, and that I did help him.” It’s clear that to Dr. Ting, the complicated moral experience that he faces within and beyond his office is worth it when he can aid individuals  that are so desperately in need of his care.



  1. “What is Gender Dysphoria?” American Psychiatric Association.
  2. Mason, Katherine. “Embodiment.” (Brown University, February 14, 2022).
  3. Plemons, Eric. “The Operating Room | The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine | Books Gateway | Duke University Press,” Chapter 5.
  4. Mason, Katherine. “The Normal and the Abnormal.” (Brown University, February 7, 2022).
  5. Safer, Joshua D., Eli Coleman, Jamie Feldman, Robert Garofalo, Wylie Hembree, Asa Radix, and Jae Sevelius. “Barriers to health care for transgender individuals.” Current opinion in endocrinology, diabetes, and obesity 23, no. 2 (2016): 168-171. 10.1097/MED.0000000000000227
  6. White Hughto, Jaclyn M., Sari L. Reisner, and John E. Pachankis. “Transgender Stigma and Health: A Critical Review of Stigma Determinants, Mechanisms, and Interventions.” Social Science & Medicine 147 (December 1, 2015): 222–31.
  7. Mizock, Lauren, and Thomas K. Lewis. “Trauma in Transgender Populations: Risk, Resilience, and Clinical Care.” Journal of Emotional Abuse 8, no. 3 (August 26, 2008): 335–54.
  8. Wansom, Tanyaporn, Thomas E. Guadamuz, and Sandhya Vasan. “Transgender Populations         and HIV: Unique Risks, Challenges and Opportunities.” Journal of Virus Eradication 2, no. 2 (April 1, 2016): 87–93.
  9. Mason, Katherine. “Embodiment.” (Brown University, February 14, 2022).
  10. Mason, Katherine. “Narrative, Stories, and Healing.” (Brown University, February 23, 2022).
  11. Charon, Rita. “Narrative Medicine: Attention, Representation, Affiliation.” Narrative 13, no. 3 (2005): 261-270.
  12. McCormack, Hannah M., Tadhg E. MacIntyre, Deirdre O’Shea, Matthew P. Herring, and Mark J. Campbell. “The prevalence and cause (s) of burnout among applied psychologists: A systematic review.” Frontiers in psychology (2018): 1897.
  13. Mason, Katherine. “(Bio)medical Training and Professions.” (Brown University, March 7, 2022).