Healthcare and Transgender People in Italy

The relationship between trans people and the Italian healthcare system is a story of rights won on paper and concrete obstacles in daily practice. Italy has a system that, in theory, covers a large part of the gender-affirming pathway through the National Health Service (SSN - Servizio Sanitario Nazionale). In practice, those navigating this system encounter waiting lists that can stretch for years, profound regional disparities, and a network of specialized centers that is insufficient to meet demand. This guide explains how healthcare for trans people actually works in Italy: what is covered, what isn’t, where to go, how long the wait is, and what the patient’s rights are.

What the National Health Service (NHS) Covers

Hormone therapy: free since 2020

The most significant change in recent years occurred on October 1, 2020, with AIFA (Italian Medicines Agency) resolutions No. 104272/2020 and No. 104273/2020 [6]. Since that date, hormone drugs for gender transition have been fully covered by the NHS across the entire national territory. In practical terms, this means that testosterone (for transmasculine people) and estrogens, antiandrogens, and GnRH analogues (for transfeminine people) are free of charge, provided the prescription is based on a diagnosis of gender incongruence formulated by a specialized multidisciplinary team [2][6].

Before 2020, the situation was fragmented: some regions like Emilia-Romagna had already approved free medication, while others left the cost entirely up to the patient [12]. The AIFA resolutions unified the framework, eliminating at least this disparity.

Specialist visits and exams

Appointments at public gender identity centers—endocrinological, psychological, and psychiatric consultations—are subject to standard NHS co-pays (ticket), generally ranging between 25 and 40 euros per visit. Those entitled to exemptions based on income or specific conditions do not pay this fee. Blood tests required to monitor hormone therapy are also covered by the NHS subject to the co-pay fee.

Surgeries

Gender-affirming surgeries—mastectomy, vaginoplasty, phalloplasty, breast augmentation, hysterectomy—can be performed under the NHS at centers that offer them, requiring only the payment of the standard co-pay [3]. In Italy, about 60 surgeries are performed per year in NHS centers dedicated to transition [7]. This is a very low number compared to the demand, resulting in some of the longest waiting lists in Europe.

What is not covered (or is difficult to access)

Not everything falls under NHS coverage uniformly. Some treatments remain in a gray area:

• Voice therapy (Logopedics): available in some centers, absent in others. There is no uniform national coverage.
• Laser hair removal or electrolysis: generally not covered by the NHS, except in certain centers where it is part of the pre-surgical pathway (for example, before vaginoplasty) [3].
• Facial Feminization Surgery (FFS): almost never available within the Italian NHS. Those who want it must turn to the private sector, often abroad.
• Continuous psychological support: centers offer psychodiagnostic evaluation and often group psychotherapeutic support, but long-term individual psychotherapy is not always guaranteed within the public pathway.

Specialized Centers: The ONIG Network and Beyond

How the network is organized

Access to care for trans people in Italy primarily goes through the gender identity centers affiliated with ONIG (National Observatory on Gender Identity) and the public facilities mapped by the Infotrans.it portal, created by the Higher Institute of Health (ISS) and UNAR [4][5]. These centers have multidisciplinary teams consisting of psychologists, psychiatrists, endocrinologists, and, in some cases, surgeons.

The main centers are located in large cities in the Center-North [4][5]:

• Rome – SAIFIP (San Camillo-Forlanini Hospital): active since 1992, it is the most historic center in Italy. It offers psychological evaluation, endocrinological support, surgery, and a Peer Navigator service.
• Turin – CIDIGEM (AOU Città della Salute e della Scienza): reference center for the North-West, offering one of the most comprehensive surgical selections in the country, including microsurgical flap phalloplasty.
• Milan – Niguarda Hospital: ONIG reference center for Lombardy.
• Bologna – MIT Clinic (Movimento Identità Trans): operates in network with ONIG and combines clinical support with associative accompaniment.
• Florence – AOU Careggi: reference center for Tuscany.
• Naples – Federico II University: service located within the Department of Neuroscience.
• Bari – Policlinico: Regional Reference Center for Gender Dysphoria.

The problem: too few centers, too much demand

The number of centers is insufficient relative to the population that needs them. According to TGEU (Transgender Europe), Italy has a concentration of services in the Center-North, leaving large areas of the South and the Islands uncovered [8]. Someone living in Calabria, Sardinia, Basilicata, or Molise does not have a reference center in their region and must travel—often for hundreds of kilometers—to access a first appointment.

This imbalance is not an anomaly exclusive to the trans sector: it reflects the broader disparities of the Italian healthcare system between North and South. But for trans people, the impact is amplified: it is not a single visit, but a pathway requiring months or years of regular appointments.

Waiting Times: The Reality in Numbers

For the first consultation

Waiting times for the first appointment at a public center range from 1 to 12 months, depending on the center [7]. The larger centers (Rome, Turin, Milan) tend to have the longest lists, paradoxically because they are the most well-known and receive requests from all over Italy. Smaller or newly established centers may have shorter waits but often offer a more limited range of services.

For hormone therapy

From the first visit to the start of hormone therapy, the process typically takes 6-18 months in the public system [1]. This period includes the psychological evaluation phase (generally 6-12 months of consultations) and subsequent endocrinological care. Times are significantly reduced in the private pathway.

For surgery

This is where the numbers become alarming. According to an investigation by Il Sole 24 Ore, waiting lists for gender-affirming surgeries reach 5-7 years in some centers [7]. The limited number of specialized surgeons, the complexity of the procedures, and the scarcity of dedicated operating rooms create a structural bottleneck. In some regions like Lombardy and Lazio, waiting times for surgery exceed 24 months even in the most favorable cases [7].

This situation pushes many people to turn to private facilities in Italy or abroad—an expensive choice that is not accessible to everyone. Italy has agreements that allow NHS reimbursement for surgeries performed abroad, but the bureaucratic procedures to obtain it are complex and not always successful.

Public Pathway vs. Private Pathway

The public pathway

Advantages: minimal costs (only co-pays), free hormone drugs [6], integrated multidisciplinary team, possibility to access surgery under the NHS.

Disadvantages: long waiting times [7], limited ability to choose your professional, sometimes rigid protocols, limited geographical availability [8].

The private pathway

Those who choose the private sector—for faster times, the ability to choose a professional, or privacy reasons—should consider these indicative costs:

• Psychological consultations: 60-120 euros per session (weekly or bi-weekly for 6-12 months)
• Endocrinological visit: 100-200 euros
• Hormone drugs (without NHS coverage): 30-80 euros per month
• Blood tests: 50-150 euros for a complete panel

Combining public and private

The most common—and often the most pragmatic—strategy is to combine the two pathways. You can start the psychological phase privately, with a professional specialized in gender identity in your city, shortening the times. Once the psychodiagnostic report is obtained, you access the NHS for hormone therapy (which becomes free) and for surgery [1]. This hybrid strategy allows for reducing overall waiting times while maintaining public coverage for the most expensive phases of the transition.

It is important to know that not all public centers accept external psychological reports. Some require their own internal evaluation, even if abbreviated. Before starting a private path with the intention of presenting the report to a public center, it is advisable to contact the center to verify its practices.

The Italian Model: Psychological Evaluation and Gatekeeping

How it works in Italy

The Italian system requires a psychological evaluation before accessing hormone therapy [1]. This evaluation, conducted by specialized psychologists or psychotherapists, results in a psychodiagnostic report certifying the condition of gender incongruence. The duration of this phase varies from center to center: some complete the evaluation in 6 months, others take 12 months or more.

The evaluation is not intended to “authorize” or “deny” the transition. Its stated goals are:

1. To support the person in the conscious exploration of their path.
2. To verify the absence of untreated psychiatric conditions that could interfere with decision-making capacity.
3. To draft the documentation necessary for the hormone prescription and, subsequently, for legal gender recognition (name and gender marker change).

The debate: informed consent vs. gatekeeping

Internationally, there are two prevalent models for accessing gender-affirming care [13]:

The informed consent model: The adult patient, after receiving complete information about risks and benefits, autonomously decides whether to undertake hormone therapy. A mandatory psychological evaluation is not required, but psychological support is made available to those who want it. This model is widespread in the United States, in some Northern European centers, and partially in Spain.

The mandatory evaluation model (gatekeeping): Access to hormone therapy is conditional upon a psychological or psychiatric evaluation [13]. This is the model adopted in Italy, France, and most Eastern European countries.

Italy falls into the second group, although with significant differences between centers. Some Italian centers adopt an approach closer to informed consent—with shorter and less formalized evaluations—while others maintain stricter protocols. The WPATH SOC 8 guidelines (2022) recommend an approach that balances professional evaluation with respect for patient autonomy, without imposing minimum time requirements for the psychological phase [10].

The main criticism of the Italian model concerns variability: in the absence of a uniform national protocol, the duration and rigidity of the evaluation depend on the individual center, the individual professional, and, ultimately, the patient’s geographical luck [12].

Regional Disparities: The North-South Divide

Two-speed healthcare

Regional disparities in access to care for trans people reflect a structural problem in Italian healthcare, but amplify it [12]. The data speak clearly:

• Concentration of centers: the vast majority of ONIG centers and specialized facilities are located in the Center-North (Turin, Milan, Bologna, Rome, Florence) [4][5]. In the South, only Naples and Bari have structured centers. Entire regions—Calabria, Sardinia, Basilicata, Molise, Abruzzo—do not have a reference center.
• Surgical expertise: gender-affirming surgeries are performed in very few centers, almost all in the North [3]. For a phalloplasty or a vaginoplasty, a person living in Sicily must temporarily relocate to the Center-North.
• Justice system timelines: the process of legal gender recognition requires a court ruling, and the timelines of civil justice vary enormously between regions. A proceeding that concludes in 6-8 months in Turin may take over 2 years in courts with larger backlogs.
• General practitioner training: a 2024 SIMG survey highlighted that general practitioners have very limited knowledge of gender-affirming pathways [9]. This problem is widespread but becomes acute in areas where there are no specialized centers, making the GP the only point of contact with the healthcare system.

The consequences

Regional disparity has direct consequences on people’s lives. Those living far from centers must undertake long and expensive trips, often on a weekly or bi-weekly basis during the psychological phase. They must request time off work, pay for trains and accommodation, and manage the fatigue of a process that is already emotionally demanding. For those with limited economic resources, these barriers can become insurmountable.

A 2022 ISS data point is particularly significant: the level of preventive healthcare in the transgender population is very low, with trans people accessing cancer screenings and preventive check-ups less frequently than the general population [14]. Not because they don’t need them, but because their relationship with the healthcare system is often marked by experiences of discrimination, embarrassment, or simple misunderstanding.

The LEAs and the Regulatory Framework

Essential Levels of Care (LEA)

The Essential Levels of Care (LEA - Livelli Essenziali di Assistenza), defined by the DPCM of January 12, 2017, establish the services that the NHS is required to guarantee to all citizens [11]. The gender-affirming pathway falls under the services provided by the NHS, but the DPCM does not contain specific and detailed guidelines on the individual services for trans people [11][12]. This leaves ample room for interpretation to individual regions and individual ASLs (Local Health Authorities), contributing to the fragmentation of the offering.

In the absence of a national protocol that precisely defines which services, in what timeframes, and to what standards must be guaranteed to trans people, the system relies on the goodwill of individual centers and the pressure from advocacy groups [12].

Patient rights

Regardless of the region you live in, some guarantees exist and should be known:

• The right to privacy: data related to gender identity is sensitive data, protected by the GDPR and Italian healthcare regulations.
• The right to a chosen name: even before legal gender recognition, many centers use the name chosen by the person in internal communications. Some regions have issued guidelines to this effect.
• The right to informed consent: every medical treatment requires the patient’s informed consent, who must receive complete information on risks, benefits, and alternatives [10].
• Legal aid (gratuito patrocinio): for legal expenses related to legal gender recognition, State-funded legal aid is available for those who fall within the income limits.

Italy in the European Context

Where Italy stands

According to TGEU’s Trans Health Map 2024, Italy occupies a middle position in the European landscape [8]. On one hand, NHS coverage for hormone therapy and surgery is a positive aspect: not all European countries guarantee such extensive public coverage [13]. On the other hand, the access model—based on mandatory psychological evaluation and a judicial procedure for legal recognition—is far from the self-determination model adopted by twelve European countries (including Spain, Germany, Denmark, Belgium, Portugal).

What other countries do better

• Spain: the 2023 Ley Trans introduced gender self-determination and strengthened healthcare coverage, with centers distributed throughout the national territory.
• Germany: the 2024 Selbstbestimmungsgesetz simplified legal recognition, and the insurance system covers most treatments.
• Netherlands: the Dutch system is among the most established in Europe, with centers of excellence for surgery and standardized protocols, although it too suffers from significant waiting lists (1-3 years) [13].
• Belgium: the Belgian model combines public healthcare coverage with an approach closer to informed consent [13].

Italy shares the problem of waiting lists with many of these countries but stands out for its lack of a uniform national protocol and greater regional disparities [8][12].

Practical Guide: Step by Step

For those trying to concretely navigate the system, here are the essential steps.

1. Inform yourself and identify the center

Consult the Infotrans.it map and the ONIG website to identify the closest center [4][5]. Check what services it offers, the estimated waiting times, and how to access it (with or without a GP’s referral).

2. First contact

Call or write to the center to schedule a first appointment. You don’t need previous diagnoses or absolute certainty. Bring your health card (tessera sanitaria) and ID. If you already have psychological or medical reports, they can be useful but are not mandatory.

3. Psychological evaluation

The consultation phase with the center’s psychologist generally lasts 6-12 months [1]. At the end, a psychodiagnostic report is drafted. In parallel, if you want to shorten the time, you can consider a private psychological pathway—checking first with the center if an external report will be accepted.

4. Hormone therapy

With the psychodiagnostic report, the center’s endocrinologist prescribes hormone therapy [2]. Before starting, comprehensive blood tests are performed. The drugs are free through the NHS [6]. Monitoring involves tests every 3-6 months in the first year, then every 6-12 months [2].

5. Surgery (for those who want it)

Not all trans people desire surgical interventions, and it is not necessary to undergo surgery for legal gender recognition (since 2015, the Constitutional Court has eliminated this requirement). For those who want it, you are placed on the surgical center’s waiting list [3]. Times are long: it is advisable to sign up as soon as possible.

6. Legal gender recognition

With the documentation of the pathway (psychological report, endocrinological documentation), you can start the process of legal name and gender change at the court in your place of residence, assisted by a lawyer.

The Infotrans Portal: An Institutional Resource

The Infotrans.it portal deserves a specific mention. Created by the Higher Institute of Health (ISS) in collaboration with UNAR (National Anti-Racial Discrimination Office), it is the first institutional portal in Europe entirely dedicated to the health and well-being of trans people [4]. It offers:

• An interactive map of all dedicated services nationwide, with addresses, contacts, services offered, and team compositions [4].
• Information sheets on every phase of the pathway: psychological support, hormone therapy, surgery, legal gender recognition, fertility preservation [1][2][3].
• Best practices for healthcare, educational, and workplace professionals.
• A list of associations active across the territory.

Infotrans does not replace direct contact with a center, but it is the most reliable starting point for navigating a system that, as we’ve seen, is anything but linear.

Structural Problems: An Honest Picture

It would be unfair to close this guide without naming the systemic problems trans people face when interacting with Italian healthcare. Not to discourage, but because knowing them is the first step to facing them.

• Unsustainable waiting lists: up to 7 years for surgery, up to 12 months for a first consultation in the most congested centers [7].
• Insufficient training of healthcare staff: many general practitioners and healthcare workers lack specific training on gender identity, which can translate into misunderstandings, improper use of deadnames, or implicit refusals [9].
• Experiences of discrimination: according to an Arcigay survey, 38% of trans people reported hostile experiences with healthcare professionals. Almost a quarter actively avoid contact with doctors or healthcare facilities for fear of prejudice.
• Lack of a national protocol: each center operates according to its own protocols, with significant differences in times, requirements, and approaches [12]. This generates uncertainty and inequality.
• Poor prevention: trans people access cancer screenings and preventive check-ups less than the general population [14], a figure that reflects the problematic relationship with the healthcare system.

These problems are real, but they are not immutable. The system has improved significantly in recent years—free hormone drugs [6], the Infotrans portal [4], overcoming the surgical requirement for legal recognition are concrete achievements. The road is still long, but it is not the same as it was ten or twenty years ago.

Those considering starting the transition deserve to know that the system has its limits, and that despite those limits, it is possible to access effective and safe care. You don’t have to face this journey alone: associations, centers, and trans communities are valuable resources, and reaching out to them is a right, not a favor.