<p>This paper examines the treatment of transgender patients in the United States as they move into the complex simultaneous space of patient and consumer, exploring the emergence of the ‘difficult patient' of transgender medicine. Described by surgeons as a disgruntled, unsatisfied customer, surgeons attempt to wrangle the ‘difficult patient' from posting bad reviews and sharing cautionary tales, even as these same patients face medical malpractice and/or simply attempt to provide resources to transgender communities trying to carefully navigate the medical system. This paper unpacks an emerging billion-dollar industry in the U.S. that also draws international patients, as it provides and profits from an urgently needed but increasingly restricted resource. Examining discourse in medical journals, customer reviews, and professional profiles of surgeons, this paper critically challenges how the “difficult patient” of transgender medicine becomes defined through its threat to profits and to professional reputations.</p>