Trans healthcare in Spain
Not medical or legal advice
This guide is based on personal and community experience. Rules differ between regions and change over time, so always check with your doctor or official sources.
Ways to access trans healthcare
There are 3 ways to access trans healthcare in Spain:
- Through the public system, using your health card (tarjeta sanitaria individual, TSI), covered by social security. The public system is officially called the SNS (Sistema Nacional de Salud), but most people just call it “Seguridad Social”. In this guide, SS means the public system.
- Through private insurance
- Fully private, paying for appointments out of pocket
Public system
In Spain, each autonomous community (comunidad autónoma) runs its own public healthcare system, and each has its own name for the health card (for example, SIP in the Valencian Community). As a result, conditions and quality of access vary between regions, and even inside one region they can vary a lot between cities and hospitals.
Overall, there are 3 types of trans healthcare in the SS:
- Psychological support and assessment
- Pharmacotherapy (HRT and/or psychiatric medication). More info about HRT: HRT
- Surgical care (vaginoplasty, mastectomy, breast augmentation, etc.)
These are often presented as steps, but in reality some steps can be skipped, especially if you are not starting your transition but continuing it after moving to Spain (or moving within Spain).
Psychological support and assessment
Traditionally this was considered the first step to access the rest of trans healthcare. However, under the national trans law (Ley 4/2023), healthcare for trans people must follow the principles of non-pathologisation, autonomy, and informed decision and consent (Article 56). This means a psychological or psychiatric assessment should not be used as a gatekeeping requirement. In practice some units still ask for it, but it can often be skipped, especially if you are already on HRT.
If you do want psychological support, waiting times can vary a lot, because mental health services in the SS are generally considered extremely overloaded.
HRT
See HRT.
Surgical care
Surgical care varies a lot between regions. This includes what is covered by the SS, and how long you need to be followed by an endocrinologist in the system before you can get a referral for surgery.
Usually you need to be followed by a trans-specific endocrinologist in the SS for at least a year before you can get a referral for surgery. After that, you are put on a waiting list. The wait after getting on the list is usually at least a year, but in some places it is as long as 8 years. In Barcelona, the wait is often described as 2–5 years.
But there are always exceptions. For example, if you already had surgery and later developed complications, you can sometimes get surgery much sooner. The same can apply if non-surgical transition (HRT, etc.) caused complications that require surgery. This happens because such treatment can be considered medically necessary (for example reconstructive) surgery, meaning treatment of a complication, rather than gender-affirming care.
Types of gender-affirming surgery
- Vaginoplasty and orchiectomy
- Mastectomy
- Hysterectomy and adnexectomy
- Phalloplasty and metoidioplasty
- Breast augmentation
- Facial feminization surgery (FFS), very rare in the public system
- Voice feminization/masculinization surgery, very rare in the public system
This is the list of surgeries that exist in the system to some degree. In reality, not all of them are available in every region, but vaginoplasty, mastectomy, hysterectomy and breast augmentation are usually “available” everywhere. Even if a surgery is available in the system, it doesn’t mean you will get access. For example, for breast augmentation you need to meet specific criteria about your breast development and size. The rules can vary and can be applied differently depending on your doctor(s).
Access flow
In Spain the process depends on the region and your specific case, but it usually looks like one of these options:
- Family doctor → Gender/Trans Unit (trans-specific psychiatrist and/or endocrinologist)
- Family doctor → Endocrinologist (general) → Gender/Trans Unit
- Family doctor → Psychiatrist → Gender/Trans Unit → Trans-specific endocrinologist
- Psychiatrist → Gender/Trans Unit → Endocrinologist
- In some places you can contact the Gender/Trans Unit directly, without going through your family doctor. For example, in Catalonia Trànsit officially accepts people directly, but in practice it only sometimes works properly in Barcelona.
Gender/Trans Units in different hospitals and regions have different internal flows and protocols, and they may apply them differently depending on the patient’s history, status and situation. Some units have their own coordinators who decide your priority and which type of doctor you see first; in others, your family doctor can refer you not just to the unit but directly to a specific type of doctor.
Sometimes a regular endocrinologist (outside the Gender/Trans Unit, but still in the SS) can be your main and only trans healthcare provider. However, a regular endocrinologist usually can’t put you on the waiting list for gender-affirming surgery.
Private system
Psychological support and assessment
Usually not required to access HRT and most surgical care. If you need it, it’s often covered by private insurance; the conditions depend on your plan.
HRT
See HRT.
Surgical care
Paying out of pocket is mostly straightforward, and the waiting time mainly depends on the provider you choose. For most surgeries a certificate from a psychiatrist is NOT required, but clinics/surgeons still have the right to ask for one.
Spanish private insurers almost always explicitly exclude gender-affirming surgery from coverage. Exceptions exist, but they are extremely uncommon.