Explore the vast range of titles available.

Aim To understand the preferences of individuals with gender incongruence (GI) regarding gender‐affirming surgery (GAS), including gonadectomy. Methods A prospective, multicenter survey was conducted in Japan targeting individuals aged 18 years or older with GI who had not yet undergone GAS. Participants completed a questionnaire about their GAS preferences, desired surgical procedures, the reasons for their preferences, and willingness to undergo gonadectomy even if it was not legally required. Results In total, 107 participants (82 assigned female at birth [AFAB] and 25 assigned male at birth [AMAB]; median age: 31) participated in the study. Of those, 69% desired GAS, 29% did not, and 2% were undecided. The primary reasons for desiring GAS were the need for legal gender change (positive feelings: 62%, unavoidable: 24%), mental stability (56%), and reducing gender dysphoria (54%). Conversely, the main reasons for not wanting GAS were difficulty in securing funds for surgery (58%), followed by resistance to gonadectomy (41%). Of the 53 AFAB participants, 52 individuals desired hysterectomy and oophorectomy, and 26 wanted only this surgery. Among the 22 AMAB participants, 13 individuals desired vaginoplasty; however, five withdrew due to concerns about costs or postoperative complications. Even without legal requirements, 47% said they would choose gonadectomy. Conclusion Reforming legal requirements for gonadectomy may alter the demand for or details of GAS in Japan, yet half of the participants still desire surgery. The primary reason for not undergoing surgery is the difficulty in securing funds, which is a significant finding. Preferences for gender‐affirming surgery in Japan were shaped by legal and psychological factors, with financial difficulty as the main barrier.