PURPOSE: Gender-affirming surgery has been gaining traction among the surgical practice of plastic surgeons due to increased awareness and insurance coverage for these procedures. The purpose of this study is to investigate the epidemiologic trends of gender-affirming surgery across the country over the past six years. METHOD: The ACS NSQIP database was queried for gender-affirming procedures performed between 2015 and 2020. Professional surgical society guidelines, insurance reimbursement policies, and literature was reviewed in-depth to compile an elegant list of procedure code combinations to define subtypes of gender-affirming procedures. Demographics and epidemiologic trends were analyzed among procedures with appropriate statistics. RESULTS: During the study interval, 4491 patients underwent gender-affirming surgery. These were 71.1% (n=3221) transmale procedures and 28.3% (n=1270) transfemale procedures, and this proportion has stayed stable over the past six years (p=.705). However, the incidence of gender-affirming procedures significantly increased over the years from 0.030% (n=265 of 885,502) in 2015 to 0.121% (n=1092 of 902,968) in 2020 across 719 participating hospitals, representing a four-fold increase when accounting for overall changes in practice volume across all surgical specialties. Age of patients has been decreasing undergoing transgender procedures overall (p<.001, ρ= –.091, 30.0 to 27.0 years), including those undergoing transmale (p<.001, ρ= –.092, 28.0 to 25.0 years) and transfemale procedures (p=.126, ρ= –.043, 33.5 to 32.0 years). Patients undergoing transmale procedures were significantly younger than those undergoing transfemale procedures (p<.001, 22.0 vs 32.0 years). Patients undergoing top surgery were slightly younger than those undergoing bottom surgery (p<.001, 27.0 vs 29.0 years). White patients were significantly more likely to undergo transmale procedures than transfemale procedures (p<.001, 58.6% vs 45.0%), black patients were significantly more likely to undergo transfemale procedures (p<.001, 17.4% vs 9.3%), and hispanic patients were significantly more likely to undergo transfemale procedures (p<.001, 14.3% vs 7.8%). Among transmale patients, 68.8% (n=2216 of 3221) underwent top surgery and 32.4% (n=1044 of 3221) underwent bottom surgery, including 1.2% (n=39 of 3221) who underwent both top and bottom surgery during the same procedure. Among transfemale patients, 60.6% (n=769 of 1270) underwent top surgery and 41.7% (n=529 of 1270) underwent bottom surgery, including 2.2% (n=28 of 1270) who underwent both top and bottom surgery during the same procedure. There were significant differences across all of these comparisons, such that transmale patients were more likely to undergo top surgery (p<.001), transfemale patients were more likely to undergo bottom surgery (p<.001), and transfemale patients were more likely to undergo simultaneous top and bottom surgery (p=.013). CONCLUSION: As the cultural, political, and financial climate has made gender-affirming surgery more accessible, the age of patients undergoing these procedures has significantly decreased over the past six years. Transmale patients are ten years younger than transfemale patients. There is significant racial difference in white patients more likely undergoing transmale procedures, whereas black and hispanic patients are more likely to undergo transfemale procedures. Further research will be needed to elucidate the specific disparities in access to these procedures within racial, socioeconomic, and regional differences across the country.