Yes. Since Law 4/2023, gender affirmation treatments and surgeries are included in the common portfolio of the National Health System and are publicly funded: hormonal treatment, genital surgeries, mastectomies, mammoplasties, voice therapy, and prosthetic material. Coverage exists as a right, but actual access depends on the autonomous community you live in and its waiting lists.
This difference between what the law recognizes and what each health service offers in practice is key to understanding why many trans people value the private route. Below, you will see exactly what public healthcare covers, how the process begins, why there is so much disparity between territories, and what alternatives exist when the wait becomes unfeasible. If you are looking for specialized professional support, the complete process is carried out in this gender affirmation unit with a multidisciplinary team.
What does public healthcare cover after the trans law?
Law 4/2023 recognizes the right to healthcare for trans people within the National Health System in a depathologized manner, meaning without requiring a diagnosis of “gender dysphoria” or prior psychiatric reports as a prerequisite for accessing the service. The services included in the common portfolio of services are:
- Hormonal treatment (gender affirmation therapy).
- Genital affirmation surgeries (vaginoplasty, phalloplasty, metoidioplasty).
- Masculinizing mastectomy.
- Augmentation mammoplasty (breast feminization).
- Voice therapy and, in some cases, voice feminization surgery.
- Prosthetic material associated with these processes.
Their inclusion in the common portfolio means that, on paper, anyone with a health card can access them with public funding throughout the territory. The important nuance is that healthcare management has been transferred to the autonomous communities, and each decides how to organize this care, which hospitals provide it, and with what resources.
How the process begins in public healthcare
The first step is to visit your primary care physician and request a referral to your autonomous community’s gender identity care unit (also called Gender Identity Units or GIUs). From there, a specialized team in endocrinology, surgery, psychology, and gynecology or urology coordinates the different phases of the transition according to each person’s needs.
Not all communities have a reference unit with surgical capacity. When an autonomous community does not perform certain surgeries, it refers its patients to reference hospitals in other communities through the healthcare cohesion fund. This lengthens waiting times and explains a good part of the delays we will see below.
Why coverage depends on your autonomous community
Here is the point that most articles overlook. Having the recognized right does not guarantee receiving care within a reasonable timeframe. The reality of care varies greatly from one territory to another, and three factors determine this.
Waiting lists for surgery can be years long
For genital affirmation surgeries, the most complex ones, the wait can be measured in years. The Andalusian Ombudsman documented in 2024 waits of around nine years in the reference unit in Malaga, one of Spain’s pioneers, which also absorbs patients referred from other communities. The number of annual interventions had fallen (from an average of 16 before the pandemic to 2 in 2023), while demand grew.
Not all communities provide all services
Care is not homogeneous. There are communities with consolidated multidisciplinary units and others where access depends on the reference hospital assigned to you, to the point that blockages have been reported in centers that neither operate nor refer, leaving some people in a care limbo. As a recent regional report summarized, access to trans health does not always depend solely on the recognized right, but also on the postal code.
Many people end up in private healthcare
The consequence is measurable. According to the Transaludes study by the Carlos III Health Institute (2024), two out of three people who underwent surgical transition ended up doing so in private healthcare, among other reasons due to long waiting lists and barriers encountered in public healthcare. It is not a matter of aesthetic preference: it is a matter of life time.
What if I have surgery at a private clinic? Reimbursement is not guaranteed
A frequent question is whether, by having surgery privately to avoid waiting, one can later claim the money from Social Security. The honest answer is not automatically. The general rule of the system is that reimbursement of private healthcare expenses only proceeds in cases of immediate vital emergency, and courts have ruled disparately in the case of gender affirmation surgeries.
There have been rulings that have forced the reimbursement of expenses to trans people to whom public healthcare denied or delayed care, and others that have rejected the reimbursement of operations performed in private clinics. It is an area with open litigation and no single answer, so it is advisable not to assume that paying privately will later be recovered through public channels.
How much the process costs privately
The private cost depends on the procedure, technique, and complexity of each case, so there is no single price. What the private route does offer compared to the public is control over timelines (no years-long waiting lists), continuity with the same team throughout the process, and more personalized attention at each stage.
To get an accurate idea for your situation, an individual assessment is most useful. Each procedure is planned case by case, because techniques, prerequisites, and recovery vary depending on the person.
Gender Medic: the complete process with a single team
If the wait in public healthcare is unfeasible for you or you want closer support, at Gender Medic, we are a specialized unit in gender affirmation surgeries with over 25 years of experience. We carry out the complete process (surgery, endocrinology, psychology, sexology, and pelvic floor physiotherapy) in an environment of trust, honesty, and safety, with interventions performed in a reference hospital.
The first step involves no commitment: the initial advisory consultation is free, and in it, we assess your case, answer questions, and explain options and realistic timelines so you can make an informed decision.
