gender reassignment surgery essay

• Reference Manager
• Simple TEXT file

People also looked at

Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-non-conforming people, version 7. Int J Transgend. (2012) 13:165–232. doi: 10.1080/15532739.2011.700873

CrossRef Full Text | Google Scholar

2. Massie JP, Morrison SD, Maasdam JV, Satterwhite T. Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. Plast Reconstruct Surg. (2018) 141:911–921. doi: 10.1097/PRS.0000000000004427

PubMed Abstract | CrossRef Full Text | Google Scholar

3. Pan S, Honig SC. Gender-affirming surgery: current concepts. Curr Urol Rep . (2018) 19:62. doi: 10.1007/s11934-018-0809-9

4. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int . (2007) 100:607–13. doi: 10.1111/j.1464-410X.2007.07017.x

5. Rossi NR, Hintz F, Krege S, Rübben H, Vom DF, Hess J. Gender reassignment surgery – a 13 year review of surgical outcomes. Eur Urol Suppl . (2013) 12:e559. doi: 10.1016/S1569-9056(13)61042-8

6. Silva RUM, Abreu FJS, Silva GMV, Santos JVQV, Batezini NSS, Silva Neto B, et al. Step by step male to female transsexual surgery. Int Braz J Urol. (2018) 44:407–8. doi: 10.1590/s1677-5538.ibju.2017.0044

7. Aydin D, Buk LJ, Partoft S, Bonde C, Thomsen MV, Tos T. Transgender surgery in Denmark from 1994 to 2015: 20-year follow-up study. J Sex Med. (2016) 13:720–5. doi: 10.1016/j.jsxm.2016.01.012

8. Perovic SV, Stanojevic DS, Djordjevic MLJ. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. (2001) 86:843–50. doi: 10.1046/j.1464-410x.2000.00934.x

9. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. (2001) 88:396–402. doi: 10.1046/j.1464-410X.2001.02323.x

10. Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, et al. Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients. Urol International. (2010) 84:330–3. doi: 10.1159/000288238

11. Reed H. Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty. Semin PlasticSurg. (2011) 25:163–74. doi: 10.1055/s-0031-1281486

12. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. (2015) 12:1837–45. doi: 10.1111/jsm.12936

13. Sigurjonsson H, Rinder J, Möllermark C, Farnebo F, Lundgren TK. Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open. (2015) 6:69–73. doi: 10.1016/j.jpra.2015.09.003

14. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J Urol. (2018) 199:760–5. doi: 10.1016/j.juro.2017.10.013

15. Dy GW, Sun J, Granieri MA, Zhao LC. Reconstructive management pearls for the transgender patient. Curr. Urol. Rep. (2018) 19:36. doi: 10.1007/s11934-018-0795-y

16. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol. (2013) 64:141–9. doi: 10.1016/j.eururo.2012.12.030

17. Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med . (2015) 12:1499–512. doi: 10.1111/jsm.12868

18. Hadj-Moussa M, Ohl DA, Kuzon WM. Feminizing genital gender-confirmation surgery. Sex Med Rev. (2018) 6:457–68.e2. doi: 10.1016/j.sxmr.2017.11.005

19. Salim A, Poh M. Gender-affirming penile inversion vaginoplasty. Clin Plast Surg. (2018) 45:343–50. doi: 10.1016/j.cps.2018.04.001

20. Hess J, Rossi NR, Panic L, Rubben H, Senf W. Satisfaction with male-to-female gender reassignment surgery. DtschArztebl Int. (2014) 111:795–801. doi: 10.3238/arztebl.2014.0795

21. Silva DC, Schwarz K, Fontanari AMV, Costa AB, Massuda R, Henriques AA, et al. WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals. J Sex Med. (2016) 13:988–93. doi: 10.1016/j.jsxm.2016.03.370

22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

What does the scholarly research say about the effect of gender transition on transgender well-being?

We conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. We identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. We found no studies concluding that gender transition causes overall harm. As an added resource, we separately include 17 additional studies that consist of literature reviews and practitioner guidelines.

Bottom Line

This search found a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals. The literature also indicates that greater availability of medical and social support for gender transition contributes to better quality of life for those who identify as transgender.

Below are the 8 findings of our review, and links to the 72 studies on which they are based. Click here to view our methodology . Click here for a printer-friendly one-pager of this research analysis .

Suggested Citation : What We Know Project, Cornell University, “What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being?” (online literature review), 2018.

Research Findings

1. The scholarly literature makes clear that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals.

2. Among the positive outcomes of gender transition and related medical treatments for transgender individuals are improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidality, and substance use.

3. The positive impact of gender transition on transgender well-being has grown considerably in recent years, as both surgical techniques and social support have improved.

4. Regrets following gender transition are extremely rare and have become even rarer as both surgical techniques and social support have improved. Pooling data from numerous studies demonstrates a regret rate ranging from .3 percent to 3.8 percent. Regrets are most likely to result from a lack of social support after transition or poor surgical outcomes using older techniques.

5. Factors that are predictive of success in the treatment of gender dysphoria include adequate preparation and mental health support prior to treatment, proper follow-up care from knowledgeable providers, consistent family and social support, and high-quality surgical outcomes (when surgery is involved).

6. Transgender individuals, particularly those who cannot access treatment for gender dysphoria or who encounter unsupportive social environments, are more likely than the general population to experience health challenges such as depression, anxiety, suicidality and minority stress. While gender transition can mitigate these challenges, the health and well-being of transgender people can be harmed by stigmatizing and discriminatory treatment.

7. An inherent limitation in the field of transgender health research is that it is difficult to conduct prospective studies or randomized control trials of treatments for gender dysphoria because of the individualized nature of treatment, the varying and unequal circumstances of population members, the small size of the known transgender population, and the ethical issues involved in withholding an effective treatment from those who need it.

8. Transgender outcomes research is still evolving and has been limited by the historical stigma against conducting research in this field. More research is needed to adequately characterize and address the needs of the transgender population.

Below are 51 studies that found that gender transition improves the well-being of transgender people. Click here to jump to 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being.

Ainsworth and spiegel, 2010.

Ainsworth, T., & Spiegel, J. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research , 19 (7), 1019-1024.

Objectives: To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery. Methods: Facial Feminization Surgery outcomes evaluation survey and the SF-36v2 quality of life survey were administered to male-to-female transgender individuals via the Internet and on paper. A total of 247 MTF participants were enrolled in the study. Results: Mental health-related quality of life was statistically diminished (P < 0.05) in transgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. There was no statistically significant difference in the mental health-related quality of life among transgendered women who had GRS, FFS, or both. Participants who had FFS scored statistically higher (P < 0.01) than those who did not in the FFS outcomes evaluation. Conclusions: Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

Bailey, Ellis, & McNeil, 2014

Bailey, L., Ellis, S. J., & McNeil, J. (2014). Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. The Mental Health Review , 19 (4), 209-220.

Purpose: The purpose of this paper is to present findings from the Trans Mental Health Study (McNeil et al., 2012) – the largest survey of the UK trans population to date and the first to explore trans mental health and well-being within a UK context. Findings around suicidal ideation and suicide attempt are presented and the impact of gender dysphoria, minority stress and medical delay, in particular, are highlighted. Design/methodology/approach: This represents a narrative analysis of qualitative sections of a survey that utilised both open and closed questions. The study drew on a non-random sample (n 1⁄4 889), obtained via a range of UK-based support organisations and services. Findings: The study revealed high rates of suicidal ideation (84 per cent lifetime prevalence) and attempted suicide (48 per cent lifetime prevalence) within this sample. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk within this sample. Research limitations/implications: Due to the limitations of undertaking research with this population, the research is not demographically representative. Practical implications: The study found that trans people are most at risk prior to social and/or medical transition and that, in many cases, trans people who require access to hormones and surgery can be left unsupported for dangerously long periods of time. The paper highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritise timely intervention and support. Originality/value: The first exploration of suicidal ideation and suicide attempt within the UK trans population revealing key findings pertaining to social and medical transition, crucial for policy makers, commissioners and practitioners working across gender identity services, mental health services and suicide prevention.

Bar et al., 2016

Bar, M. A., Jarus, T., Wada, M., Rechtman, L., & Noy, E. (2016). Male-to-female transitions: Implications for occupational performance, health, and life satisfaction. The Canadian Journal of Occupational Therapy , 83 (2), 72-82.

Background. People who undergo a gender transition process experience changes in different everyday occupations. These changes may impact their health and life satisfaction. Purpose. This study examined the difference in the occupational performance history scales (occupational identity, competence, and settings) between male-to-female transgender women and cisgender women and the relation of these scales to health and life satisfaction. Method. Twenty-two transgender women and 22 matched cisgender women completed a demographic questionnaire and three reliable measures in this cross-sectional study. Data were analyzed using a two-way analysis of variance and multiple linear regressions. Findings. The results indicate lower performance scores for the transgender women. In addition, occupational settings and group membership (transgender and cisgender groups) were found to be predictors of life satisfaction. Implications. The present study supports the role of occupational therapy in promoting occupational identity and competence of transgender women and giving special attention to their social and physical environment.

Bodlund and Kullgren, 1996

Bodlund, O., & Kullgren, G. (1996). Transsexualism–general outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex. Archives of Sexual Behavior , 25 (3), 303-316.

Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

Bouman et al., 2016

Bouman, W. P., Claes, L., Marshall, E., Pinner, G. T., Longworth, J., et al. (2016). Sociodemographic variables, clinical features, and the role of preassessment cross-sex hormones in older trans people. The Journal of Sexual Medicine , 13 (4), 711-719.

Introduction: As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. Aims: The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. Methods: Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. Main Outcome Measures: Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire). Results: The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n = 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained. Conclusion: The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.

Boza and Nicholson, 2014

Boza, C., & Nicholson Perry, K. (2014). Gender-related victimization, perceived social support, and predictors of depression among transgender Australians. International Journal Of Transgenderism , 15 (1), 35-52.

This study examined mental health outcomes, gender-related victimization, perceived social support, and predictors of depression among 243 transgender Australians (n= 83 assigned female at birth, n= 160 assigned male at birth). Overall, 69% reported at least 1 instance of victimization, 59% endorsed depressive symptoms, and 44% reported a previous suicide attempt. Social support emerged as the most significant predictor of depressive symptoms (p>.05), whereby persons endorsing higher levels of overall perceived social support tended to endorse lower levels of depressive symptoms. Second to social support, persons who endorsed having had some form of gender affirmative surgery were significantly more likely to present with lower symptoms of depression. Contrary to expectations, victimization did not reach significance as an independent risk factor of depression (p=.053). The pervasiveness of victimization, depression, and attempted suicide represents a major health concern and highlights the need to facilitate culturally sensitive health care provision.

Budge et al., 2013

Budge, S. L., Katz-Wise, S. L., Tebbe, E. N., Howard, K. A. S., Schneider, C. L., et al. (2013). Transgender emotional and coping processes: Facilitative and avoidant coping throughout gender transitioning. The Counseling Psychologist , 41 (4), 601-647.

Eighteen transgender-identified individuals participated in semi-structured interviews regarding emotional and coping processes throughout their gender transition. The authors used grounded theory to conceptualize and analyze the data. There were three distinct phases through which the participants described emotional and coping experiences: (a) pretransition, (b) during the transition, and (c) posttransition. Five separate themes emerged, including descriptions of coping mechanisms, emotional hardship, lack of support, positive social support, and affirmative emotional experiences. The authors developed a model to describe the role of coping mechanisms and support experienced throughout the transition process. As participants continued through their transitions, emotional hardships lessened and they used facilitative coping mechanisms that in turn led to affirmative emotional experiences. The results of this study are indicative of the importance of guiding transgender individuals through facilitative coping experiences and providing social support throughout the transition process. Implications for counselors and for future research are discussed.

Cardoso da Silva et al., 2016

Cardoso da Silva, D., Schwarz, K., Fontanari, A.M.V., Costa, A.B., Massuda, R., et al. (2016). WHOQOL-100 Before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. Journal of Sexual Medicine , 13 (6), 988-993.

Introduction: The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS). Aim: To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100. Methods: This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS. Main Outcome Measures: Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS. Results: The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results. Conclusion: The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence.

(Due to a citation error, this study was initially listed twice.)

Castellano et al., 2015

Castellano, E., Crespi, C., Dell’Aquila, R., Rosato, C., Catalano, V., et al. (2015). Quality of life and hormones after sex reassignment surgery.  Journal of Endocrinological Investigation , 38 (12), 1373-1381.

Background: Transpeople often look for sex reassignment surgery (SRS) to improve their quality of life (QoL). The hormonal therapy has many positive effects before and after SRS. There are no studies about correlation between hormonal status and QoL after SRS. Aim: To gather information on QoL, quality of sexual life and body image in transpeople at least 2 years after SRS, to compare these results with a control group and to evaluate the relations between the chosen items and hormonal status. Subjects and methods: Data from 60 transsexuals and from 60 healthy matched controls were collected. Testosterone, estradiol, LH and World Health Organization Quality of Life (WHOQOL-100) self-reported questionnaire were evaluated. Student’s t test was applied to compare transsexuals and controls. Multiple regression model was applied to evaluate WHOQOL’s chosen items and LH. Results: The QoL and the quality of body image scores in transpeople were not statistically different from the matched control groups’ ones. In the sexual life subscale, transwomen’s scores were similar to biological women’s ones, whereas transmen’s scores were statistically lower than biological men’s ones (P = 0.003). The quality of sexual life scored statistically lower in transmen than in transwomen (P = 0.048). A significant inverse relationship between LH and body image and between LH and quality of sexual life was found. Conclusions: This study highlights general satisfaction after SRS. In particular, transpeople’s QoL turns out to be similar to Italian matched controls. LH resulted inversely correlated to body image and sexual life scores.

Colizzi, Costa, & Todarello, 2014

Colizzi, M., Costa, R. & Todarello, O. (2014). Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study.  Psychoneuroendocrinology , 39 , 65-73.

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients’ mental health.

Colizzi et al., 2013

Colizzi. M., Costa, R., Pace, V., & Todarello, O. (2013). Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. The Journal of Sexual Medicine , 10 (12), 3049–3058.

Introduction: Gender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic–pituitary–adrenal system dysregulation and subjective stress. Aim: The objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern. Methods: We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers. Main Outcome Measures: We used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self‐reported perceived stress and the Adult Attachment Interview to determine attachment styles. Results: At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P < 0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment. Conclusion: Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be.

Colton-Meier et al., 2011

Colton-Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay & Lesbian Mental Health , 15 (3), 281-299.

Hormonal interventions are an often-sought option for transgender individuals seeking to medically transition to an authentic gender. Current literature stresses that the effects and associated risks of hormone regimens should be monitored and well understood by health care providers (Feldman & Bockting, 2003). However, the positive psychological effects following hormone replacement therapy as a gender affirming treatment have not been adequately researched. This study examined the relationship of hormone replacement therapy, specifically testosterone, with various mental health outcomes in an Internet sample of more than 400 self-identified female-to-male transsexuals. Results of the study indicate that female-to-male transsexuals who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Testosterone use was not related to problems with drugs, alcohol, or suicidality. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.

Costantino et al., 2013

Costantino, A., Cerpolini, S., Alvisi, S., Morselli, P. G., Venturoli, S., & Meriggiola, M. C. (2013). A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. Journal of Sex & Marital Therapy , 39 (4), 321-335.

Testosterone administration in female-to-male transsexual subjects aims to develop and maintain the characteristics of the desired sex. Very little data exists on its effects on sexuality of female-to-male transsexuals. The aim of this study was to evaluate sexual function and mood of female-to-male transsexuals from their first visit, throughout testosterone administration and after sex reassignment surgery. Participants were 50 female-to-male transsexual subjects who completed questionnaires assessing sexual parameters and mood. The authors measured reproductive hormones and hematological parameters. The results suggest a positive effect of testosterone treatment on sexual function and mood in female-to-male transsexual subjects.

Davis and Meier, 2014

Davis, S. A. & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health , 26 (2), 113-128.

Objectives: This study examined the effects of testosterone treatment with or without chest reconstruction surgery (CRS) on mental health in female-to-male transgender people (FTMs). Methods: More than 200 FTMs completed a written survey including quantitative scales to measure symptoms of anxiety and depression, feelings of anger, and body dissatisfaction, as well as qualitative questions assessing shifts in sexuality after the initiation of testosterone. Fifty-seven percent of participants were taking testosterone and 40% had undergone CRS. Results: Cross-sectional analysis using a between-subjects multivariate analysis of variance showed that participants who were receiving testosterone endorsed fewer symptoms of anxiety and depression as well as less anger than the untreated group. Participants who had CRS in addition to testosterone reported less body dissatisfaction than both the testosterone-only or the untreated groups. Furthermore, participants who were injecting testosterone on a weekly basis showed significantly less anger compared with those injecting every other week. In qualitative reports, more than 50% of participants described increased sexual attraction to nontransgender men after taking testosterone. Conclusions: Results indicate that testosterone treatment in FTMs is associated with a positive effect on mental health on measures of depression, anxiety, and anger, while CRS appears to be more important for the alleviation of body dissatisfaction. The findings have particular relevance for counselors and health care providers serving FTM and gender-variant people considering medical gender transition.

De Cuypere et al., 2006

De Cuypere, G., Elaut, E., Heylens, G., Maele, G. V., Selvaggi, G., et al. (2006). Long-term follow-up: Psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies , 15 (2), 126-133.

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects’ initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Dhejne et al., 2014

Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An analysis of all applications for sex reassignment surgery in sweden, 1960-2010: Prevalence, incidence, and regrets. Archives of Sexual Behavior , 43 (8), 1535-1545.

Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2 % regret rate for both sexes. There was a significant decline of regrets over the time period.

Eldh, Berg, & Gustafsson, 1997

Eldh, J., Berg, A., Gustafsson, M. (1997). Long-term follow up after sex reassignment surgery. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery , 27 (1), 39-45.

A long-term follow up of 136 patients operated on for sex reassignment was done to evaluate the surgical outcome. Social and psychological adjustments were also investigated by a questionnaire in 90 of these 136 patients. Optimal results of the operation are essential for a successful outcome. Personal and social instability before operation, unsuitable body build, and age over 30 years at operation correlated with unsatisfactory results. Adequate family and social support is important for postoperative functioning. Sex reassignment had no influence on the person’s ability to work.

Fisher et al., 2014

Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., et al. (2014). Cross‐sex hormonal treatment and body uneasiness in individuals with gender dysphoria. The Journal of Sexual Medicine , 11 (3), 709–719.

Introduction: Cross‐sex hormonal treatment (CHT) used for gender dysphoria (GD) could by itself affect well‐being without the use of genital surgery; however, to date, there is a paucity of studies investigating the effects of CHT alone. Aims: This study aimed to assess differences in body uneasiness and psychiatric symptoms between GD clients taking CHT and those not taking hormones (no CHT). A second aim was to assess whether length of CHT treatment and daily dose provided an explanation for levels of body uneasiness and psychiatric symptoms. Methods: A consecutive series of 125 subjects meeting the criteria for GD who not had genital reassignment surgery were considered. Main Outcome Measures: Subjects were asked to complete the Body Uneasiness Test (BUT) to explore different areas of body‐related psychopathology and the Symptom Checklist‐90 Revised (SCL‐90‐R) to measure psychological state. In addition, data on daily hormone dose and length of hormonal treatment (androgens, estrogens, and/or antiandrogens) were collected through an analysis of medical records. Results: Among the male‐to‐female (MtF) individuals, those using CHT reported less body uneasiness compared with individuals in the no‐CHT group. No significant differences were observed between CHT and no‐CHT groups in the female‐to‐male (FtM) sample. Also, no significant differences in SCL score were observed with regard to gender (MtF vs. FtM), hormone treatment (CHT vs. no‐CHT), or the interaction of these two variables. Moreover, a two‐step hierarchical regression showed that cumulative dose of estradiol (daily dose of estradiol times days of treatment) and cumulative dose of androgen blockers (daily dose of androgen blockers times days of treatment) predicted BUT score even after controlling for age, gender role, cosmetic surgery, and BMI. Conclusions: The differences observed between MtF and FtM individuals suggest that body‐related uneasiness associated with GD may be effectively diminished with the administration of CHT even without the use of genital surgery for MtF clients. A discussion is provided on the importance of controlling both length and daily dose of treatment for the most effective impact on body uneasiness.

Glynn et al., 2016

Glynn, T. R., Gamarel, K. E., Kahler, C. W., Iwamoto, M., Operario, D., & Nemoto, T. (2016). The role of gender affirmation in psychological well-being among transgender women. Psychology Of Sexual Orientation And Gender Diversity , 3 (3), 336-344.

High prevalence of psychological distress, including greater depression, lower self-esteem, and suicidal ideation, has been documented across numerous samples of transgender women and has been attributed to high rates of discrimination and violence. According to the gender affirmation framework (Sevelius, 2013), access to sources of gender-affirmative support can offset such negative psychological effects of social oppression. However, critical questions remain unanswered in regards to how and which aspects of gender affirmation are related to psychological well-being. The aims of this study were to investigate the associations among 3 discrete areas of gender affirmation (psychological, medical, and social) and participants’ reports of psychological well-being. A community sample of 573 transgender women with a history of sex work completed a 1-time self-report survey that assessed demographic characteristics, gender affirmation, and mental health outcomes. In multivariate models, we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem whereas no domains of affirmation were significantly associated with suicidal ideation. Findings support the need for accessible and affordable transitioning resources for transgender women to promote better quality of life among an already vulnerable population. However, transgender individuals should not be portrayed simplistically as objects of vulnerability, and research identifying mechanisms to promote wellness and thriving is necessary for future intervention development. As the gender affirmation framework posits, the personal experience of feeling affirmed as a transgender person results from individuals’ subjective perceptions of need along multiple dimensions of gender affirmation. Thus, personalized assessment of gender affirmation may be a useful component of counseling and service provision for transgender women.

Gomez-Gil et al., 2012

Gomez-Gil, E., Zubiaurre-Elorz, L., Esteva, I., Guillamon, A., Godas, T., Cruz Almaraz, M., Halperin, I., Salamero, M. (2012). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology , 37 (5), 662-670.

Introduction: The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals. Methods: We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety. Results: The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F = 4.362, p = .038; F = 14.589, p = .001; F = 9.523, p = .002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively). Conclusions: The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Gomez-Gil et al., 2014

Gómez-Gil, E., Zubiaurre-Elorza, L., de Antonio, E. D., Guillamon, A., & Salamero, M. (2014). Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery. Quality of Life Research , 23 (2), 669-676.

Purpose: To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL. Methods: A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire). Results: Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor. Conclusions: Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Gorin-Lazard et al., 2012

Gorin‐Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Gebleux, S., Penochet, J., Pringuey, D., Albarel, F., Morange, I., Loundou, A., Berbis, J., Auquier, P., Lançon, C. and Bonierbale, M. (2012). Is hormonal therapy associated with better quality of life in transsexuals? A cross‐sectional study. The Journal of Sexual Medicine , 9 (2), 531–541.

Introduction: Although the impact of sex reassignment surgery on the self‐reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce. Aims: The objectives of this study were to assess the relationship between hormonal therapy and the self‐reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross‐sex hormone therapy as well as between transsexuals and the general population (French age‐ and sex‐matched controls). Methods: This study incorporated a cross‐sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM‐IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre‐sex reassignment surgery. Main Outcome Measure. QoL was assessed using the Short Form 36 (SF‐36). Results: The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty‐four (72.1%) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF‐36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals’ QoL, independently of hormonal status, did not differ from the French age‐ and sex‐matched controls except for two subscales of the SF‐36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls). Conclusion: The present study suggests a positive effect of hormone therapy on transsexuals’ QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.

Gorin-Lazard et al., 2013

Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Penochet, J. C., et al. (2013). Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. Journal of Nervous and Mental Disease , 201 (11), 996–1000.

Few studies have assessed the role of cross-sex hormones on psychological outcomes during the period of hormonal therapy preceding sex reassignment surgery in transsexuals. The objective of this study was to assess the relationship between hormonal therapy, self-esteem, depression, quality of life (QoL), and global functioning. This study incorporated a cross-sectional design. The inclusion criteria were diagnosis of gender identity disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and inclusion in a standardized sex reassignment procedure. The outcome measures were self-esteem (Social Self-Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning). Sixty-seven consecutive individuals agreed to participate. Seventy-three percent received hormonal therapy. Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater “psychological-like” dimensions of QoL. These findings should provide pertinent information for health care providers who consider this period as a crucial part of the global sex reassignment procedure.

Hess et al., 2014

Hess, J., Neto, R. R., Panic, L., Rübben, H., & Senf, W. (2014). Satisfaction with male-to-female gender reassignment surgery: Results of a retrospective analysis. Deutsches Ärzteblatt International , 111 (47), 795–801.

Background: The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery. Methods: 254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital’s Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction. Results: 119 (46.9%) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1–7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now. Conclusion: The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.

Heylens et al., 2014

Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., & De Cuypere, G. (2014). Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. The Journal of Sexual Medicine , 11 (1), 119–126.

Introduction: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. Aims: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. Methods: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist‐90 (SCL‐90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. Main Outcome Measures: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. Results: A difference in SCL‐90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL‐90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre‐ and postoperative assessments. Conclusions: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Imbimbo et al., 2009

Imbimbo, C., Verze, P., Palmieri, A., Longo, N., Fusco, F., Arcaniolo, D., & Mirone, V. (2009). A report from a single institute’s 14-year experience in treatment of male-to-female transsexuals. The Journal of Sexual Medicine , 6 (10), 2736–2745.

Introduction: Gender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion. Aim: The aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS. Methods: From January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire. Main Outcome Measures: The questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction. Results: Average age was 31 years old. Seventy-two percent had a high educational level, and 63% were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4% had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina’s esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets. Conclusions: Our patients’ high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up.

Johansson et al., 2010

Johansson, A., Sundbom, E., Höjerback, T., & Bodlund, O. (2010). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of Sexual Behavior , 39 (6), 1429-1437.

This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69%) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At follow-up, 32 patients had completed sex reassignment surgery, five were still in process, and five—following their own decision—had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5–15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years), and non-homosexually oriented (56 vs. 15%). In conclusion, almost all patients were satisfied with the sex reassignment; 86% were assessed by clinicians at follow-up as stable or improved in global functioning.

Keo-Meier et al., 2015

Keo-Meier, C. L., Herman, L. I., Reisner, S. L., Pardo, S. T., Sharp, C., & Babcock, J. C. (2015). Testosterone treatment and MMPI-2 improvement in transgender men: A prospective controlled study. Journal of Consulting and Clinical Psychology, 83 , 143-156.

Objective: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects. Method: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI–2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender × Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds. Results: Statistically significant changes in MMPI–2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity–Femininity scores (p < .01). Gender × Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05). Conclusions: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men.

Kraemer et al., 2008

Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology , 41 (2), 96-100.

Background: To achieve a detailed view of the body image of transsexual patients, an assessment of perception, attitudes and experiences about one’s own body is necessary. To date, research on the body image of transsexual patients has mostly covered body dissatisfaction with respect to body perception. Sampling and Methods: We investigated 23 preoperative (16 male-to-female and 7 female-to-male transsexual patients) and 22 postoperative (14 male-to-female and 8 female-to-male) transsexual patients using a validated psychological measure for body image variables. Results: We found that preoperative transsexual patients were insecure and felt unattractive because of concerns about their body image. However, postoperative transsexual patients scored high on attractiveness and self-confidence. Furthermore, postoperative transsexual patients showed low scores for insecurity and concerns about their body. Conclusions: Our results indicate an improvement of body image concerns for transsexual patients following standards of care for gender identity disorder. Follow-up studies are recommended to confirm the assumed positive outcome of standards of care on body image.

Landen et al., 1998

Landén, M., Wålinder, J., Hambert, G., & Lundström, B. (1998). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica , 97 (4), 284-289.

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient’s family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Lawrence, 2003

Lawrence, A. A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior , 32 (4), 299-315.

This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.

Lawrence, 2006

Lawrence, A. A. (2006). Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Archives of Sexual Behavior , 35 (6), 717-727.

This study examined preoperative preparations, complications, and physical and functional outcomes of male-to-female sex reassignment surgery (SRS), based on reports by 232 patients, all of whom underwent penile-inversion vaginoplasty and sensate clitoroplasty, performed by one surgeon using a consistent technique. Nearly all patients discontinued hormone therapy before SRS and most reported that doing so created no difficulties. Preoperative electrolysis to remove genital hair, undergone by most patients, was not associated with less serious vaginal hair problems. No patients reported rectal-vaginal fistula or deep-vein thrombosis and reports of other significant surgical complications were uncommon. One third of patients, however, reported urinary stream problems. No single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation. Frequency of achieving orgasm after SRS was not significantly associated with most general measures of satisfaction. Later years of surgery, reflecting greater surgeon experience, were not associated with lower prevalence rates for most complications or with better ratings for most physical and functional outcomes of SRS.

Lobato et al., 2006

Lobato M. I., Koff, W. J., Manenti, C., da Fonseca Seger, D., Salvador, J., et al. (2006). Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort.  Archives of Sexual Behavior, 35(6) , 711–715.

This study examined the impact of sex reassignment surgery on the satisfaction with sexual experience, partnerships, and relationship with family members in a cohort of Brazilian transsexual patients. A group of 19 patients who received sex reassignment between 2000 and 2004 (18 male- to-female, 1 female-to-male) after a two-year evaluation by a multidisciplinary team, and who agreed to participate in the study, completed a written questionnaire. Mean age at entry into the program was 31.21 ± 8.57 years and mean schooling was 9.2 ± 1.4 years. None of the patients reported regret for having undergone the surgery. Sexual experience was considered to have improved by 83.3% of the patients, and became more frequent for 64.7% of the patients. For 83.3% of the patients, sex was considered to be pleasurable with the neovagina/neopenis. In addition, 64.7% reported that initiating and maintaining a relationship had become easier. The number of patients with a partner increased from 52.6% to 73.7%. Family relationships improved in 26.3% of the cases, whereas 73.7% of the patients did not report a difference. None of the patients reported worse relationships

Manieri et al., 2014

Manieri, C., Castellano, E., Crespi, C., Di Bisceglie, C., Dell’Aquila, C., et al. (2014). Medical treatment of subjects with gender identity disorder: The experience in an Italian public health center. International Journal Of Transgenderism , 15 (2), 53-65.

Hormonal treatment is the main element during the transition program for transpeople. The aim of this paper is to describe the care and treatment of subjects, highlighting both the endocrine-metabolic effects of the hormonal therapy and the quality of life during the first year of cross-sex therapy in an Italian gender team. We studied 83 subjects (56 male-to-female [MtF], 27 female-to-male [FtM]) with hematological and hormonal evaluations every 3 months during the first year of hormonal therapy. MtF persons were treated with 17βestradiol and antiandrogens (cyproterone acetate, spironolactone, dutasteride); FtM persons were treated with transdermal or intramuscular testosterone. The WHO Quality of Life questionnaire was administered at the beginning and 1 year later. Hormonal changes paralleled phenotype modifications with wide variability. Most of both MtF and FtM subjects reported a statistically significant improvement in body image (p < 0.05). In particular, MtF subjects reported a statistically significant improvement in the quality of their sexual life and in the general quality of life (p < 0.05) 1 year after treatment initiation. Cross-sex therapy seems to be free of major risks in healthy subjects under clinical supervision during the first year. Selected subjects show an optimal adaptation to hormone-induced neuropsychological modifications and satisfaction regarding general and sexual life.

Megeri and Khoosal, 2007

Megeri, D., & Khoosal, D. (2007). Anxiety and depression in males experiencing gender dysphoria. Sexual & Relationship Therapy , 22 (1), 77-81.

Objective: The aim of the study was to compare anxiety and depression scores for the first 40 male to female people experiencing gender dysphoria attending the Leicester Gender Identity Clinic using the same sample as control pre and post gender realignment surgery. Hypothesis: There is an improvement in the scores of anxiety and depression following gender realignment surgery among people with gender dysphoria (male to female – transwomen). Results: There was no significant change in anxiety and depression scores in people with gender dysphoria (male to female) pre- and post-operatively.

Nelson, Whallett, & Mcgregor, 2009

Nelson, L., Whallett, E., & McGregor, J. (2009). Transgender patient satisfaction following reduction mammaplasty. Journal of Plastic, Reconstructive & Aesthetic Surgery , 62 (3), 331-334.

Aim: To evaluate the outcome of reduction mammaplasty in female-to-male transgender patients. Method: A 5-year retrospective review was conducted on all female-to-male transgender patients who underwent reduction mammaplasty. A postal questionnaire was devised to assess patient satisfaction, surgical outcome and psychological morbidity. Results: Seventeen patients were identified. The senior author performed bilateral reduction mammaplasties and free nipple grafts in 16 patients and one patient had a Benelli technique reduction. Complications included two haematomas, one wound infection, one wound dehiscence and three patients had hypertrophic scars. Secondary surgery was performed in seven patients and included scar revision, nipple reduction/realignment, dog-ear correction and nipple tattooing. The mean follow-up period after surgery was 10 months (range 2–23 months). Twelve postal questionnaires were completed (response rate 70%). All respondents expressed satisfaction with their result and no regret. Seven patients had nipple sensation and nine patients were satisfied with nipple position. All patients thought their scars were reasonable and felt that surgery had improved their self-confidence and social interactions. Conclusion: Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

Newfield et al., 2006

Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender quality of life. Quality of Life Research , 15 (9), 1447-1457.

Objectives: We evaluated health-related quality of life in female-to-male (FTM) transgender individuals, using the Short-Form 36-Question Health Survey version 2 (SF-36v2). Methods: Using email, Internet bulletin boards, and postcards, we recruited individuals to an Internet site ( http://www.transurvey.org ), which contained a demographic survey and the SF36v2. We enrolled 446 FTM transgender and FTM transsexual participants, of which 384 were from the US. Results: Analysis of quality of life health concepts demonstrated statistically significant (p<0.0\) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (/?<0.01) than those who had not received hormone therapy. Conclusions: FTM transgender participants reported significantly reduced mental health-related quality of life and

Padula, Heru, & Campbell, 2016

Padula, W. V., Heru, S. & Campbell, J. D. (2016). Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: A cost-effectiveness analysis. Journal of General Internal Medicine , 31 ( 4), 394-401.

Background: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. Objective: To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. Design: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). Patients: U.S. transgender population starting before transitional therapy. Interventions: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. Main Measures: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. Key Results: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000–22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints —HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations. Conclusions: Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.

Parola et al., 2010

Parola, N., Bonierbale, M., Lemaire, A., Aghababian, V., Michel, A., & Lançon, C. (2010). Study of quality of life for transsexuals after hormonal and surgical reassignment. Sexologies , 19 (1), 24-28.

Aim: The main objective of this work is to provide a more detailed assessment of the impact of surgical reassignment on the most important aspects of daily life for these patients. Our secondary objective was to establish the influence of various factors likely to have an impact on the quality of life (QoL), such as biological gender and the subject’s personality. Methods: A personality study was conducted using Eysenck Personality Inventory (EPI) so as to analyze two aspects of the personality (extraversion and neuroticism). Thirty-eight subjects who had undergone hormonal surgical reassignment were included in the study. Results: The results show that gender reassignment surgery improves the QoL for transsexuals in several different important areas: most are satisfied of their sexual reassignment (28/30), their social (21/30) and sexual QoL (25/30) are improved. However, there are differences between male-to-female (MtF) and female-to-male (FtM) transsexuals in terms of QoL: FtM have a better social, professional, friendly lifestyles than MtF. Finally, the results of this study did not evidence any influence by certain aspects of the personality, such as extraversion and neuroticism, on the QoL for reassigned subjects.

Pfäfflin, 1993

Pfäfflin, F. (1993). Regrets after sex reassignment surgery. Journal of Psychology & Human Sexuality , 5 (4), 69-85.

Using data draw from the follow-up literature covering the last 30 years, and the author’s clinical data on 295 men and women after SRS, an estimation of the number of patients who regretted the operations is made. Among female-to-male transsexuals after SRS, i.e., in men, no regrets were reported in the author’s sample, and in the literature they amount to less than 1%. Among male-to- female transsexuals after SRS, i.e., in women, regrets are reported in 1-1.5%. Poor differential diagnosis, failure to carry out the real-life- test, and poor surgical results seem to be the main reasons behind the regrets reported in the literature. According to three cases observed by the author in addition to personality traits the lack of proper care in treating the patients played a major role.

Pimenoff and Pfäfflin, 2011

Pimenoff, V., & Pfäfflin, F. (2011). Transsexualism: Treatment outcome of compliant and noncompliant patients. International Journal Of Transgenderism , 13 (1), 37-44.

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Rakic et al., 1996

Rakic, Z., Starcevic, V., Maric, J., & Kelin, K. (1996). The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes. Archives of Sexual Behavior , 25 (5), 515-525.

Several aspects of the quality of life after sex reassignment surgery in 32 transsexuals of both sexes (22 men, 10 women) were examined. The Belgrade Team for Gender Identity Disorders designed a standardized questionnaire for this purpose. The follow-up period after operation was from 6 months to 4 years, and four aspects of the quality of life were examined: attitude towards the patients’ own body, relationships with other people, sexual activity, and occupational functioning. In most transsexuals, the quality of life was improved after surgery inasmuch as these four aspects are concerned. Only a few transsexuals were not satisfied with their life after surgery.

Rehman et al., 1999

Rehman, J., Lazer, S., Benet, A. E., Schaefer, L. C., & Melman, A. (1999). The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Archives of Sexual Behavior , 28 (1), 71-89.

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (A.M.). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced post operatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Rotondi et al., 2011

Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Canadian Journal Of Community Mental Health , 30 (2), 135-155.

Although depression is understudied in transgender and transsexual communities, high prevalences have been reported. This paper presents original research from the Trans PULSE Project, an Ontario-wide, community-based initiative that surveyed 433 participants using respondent-driven sampling. The purpose of this analysis was to determine the prevalence of, and risk and protective factors for, depression among female-to-male (FTM) Ontarians (n = 207). We estimate that 66.4% of FTMs have symptomatology consistent with depression. In multivariable analyses, sexual satisfaction was a strong protective factor. Conversely, experiencing transphobia and being at the stage of planning but not having begun a medical transition (hormones and/or surgery) adversely affected mental health in FTMs.

Ruppin and Pfäfflin, 2015

Ruppin, U., & Pfäfflin, F. (2015). Long-term follow-up of adults with gender identity disorder. Archives of Sexual Behavior , 44 (5), 1321-1329.

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants’ gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10–24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Smith et al., 2005

Smith, Y. L. S., Van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. (2005). Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 35 (1), 89-99.

Background: We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome. Method: Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses. Results: After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes. Conclusions: The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.

van de Grift et al., 2017

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., Cuypere, G. D., Richter-Appelt, H., & Kreukels, B. P. (2017). Effects of medical interventions on gender dysphoria and body image. Psychosomatic Medicine , 79 (7), 815-823.

Objective: The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. Methods: Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). Results: At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. Conclusions: Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., & Kreukels, B. P. (2017). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. Journal of Sex & Marital Therapy , 44 (2), 138-148.

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR= 6.07). Satisfied respondents’ QoL scores were similar to reference values; dissatisfied or regretful respondents’ scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

Vujovic et al., 2009

Vujovic, S., Popovic, S., Sbutega-Milosevic, G., Djordjevic, M., & Gooren, L. (2009). Transsexualism in Serbia: A twenty-year follow-up study. The Journal of Sexual Medicine , 6 (4), 1018-1023.

Introduction: Gender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment. Aim: To describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia. Methods: Data, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively. Main Outcome Measures: Age at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated. Results: Applicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10% do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision. Conclusions: Although transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.

Weigert et al., 2013

Weigert, R., Frison, E., Sessiecq, Q., Al Mutairi, K., & Casoli, V. (2013). Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plastic and Reconstructive Surgery, 132 (6), 1421-1429.

Background: Satisfaction with breasts, sexual well-being, psychosocial well-being, and physical well-being are essential outcome factors following breast augmentation surgery in male-to-female transsexual patients. The aim of this study was to measure change in patient satisfaction with breasts and sexual, physical, and psychosocial well-being after breast augmentation in male-to-female transsexual patients. Methods: All consecutive male-to-female transsexual patients who underwent breast augmentation between 2008 and 2012 were asked to complete the BREAST-Q Augmentation module questionnaire before surgery, at 4 months, and later after surgery. A prospective cohort study was designed and postoperative scores were compared with baseline scores. Satisfaction with breasts and sexual, physical, and psychosocial outcomes assessment was based on the BREAST-Q. Results: Thirty-five male-to-female transsexual patients completed the questionnaires. BREAST-Q subscale median scores (satisfaction with breasts, +59 points; sexual well-being, +34 points; and psychosocial well-being, +48 points) improved significantly (p < 0.05) at 4 months postoperatively and later. No significant change was observed in physical well-being. Conclusions: In this prospective, noncomparative, cohort study, the current results suggest that the gains in breast satisfaction, psychosocial well-being, and sexual well-being after male-to-female transsexual patients undergo breast augmentation are statistically significant and clinically meaningful to the patient at 4 months after surgery and in the long term.

Weyers et al., 2009

Weyers, S., Elaut, E., De Sutter, P., Gerris, J., T’Sjoen, G., et al. (2009). Long-term assessment of the physical, mental, and sexual health among transsexual women. The Journal of Sexual Medicine , 6 (3), 752-760.

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Methods: Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited. Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

Back to Top

Below are 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to the 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being . Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

Barrett, 1998.

Barrett J. (1998). Psychological and social function before and after phalloplasty. The International Journal of Transgenderism , 2 (1), 1-8.

There are no quantitative assessments of the benefits of phalloplasty in a female transsexual population. The study addresses this question, comparing transsexuals accepted for such surgery with transsexuals after such surgery has been performed. A population of 23 transsexuals accepted for phalloplasty was compared to a population of 40 who had undergone such surgery between six and one hundred and sixty months previously. The General Health Questionnaire (GHQ), Symptom Checklist 90 (SCL-90), Bem Sex Role Inventory and Social Role Performance Schedule (SRPS) were employed. Additionally, a questionnaire assessing satisfaction with cosmetic appearance, sexual function, relationship and urinary function was used, along with a semi-structured interview quantifying alcohol, cigarette and drug usage, and current sexual practice. There were significant differences between the populations. The post operative group showed higher depression ratings on the depression subscale of the GHQ. The masculine pre-operative Bem scores were neutral post-operatively as feminine sub-scores increased. There was improved satisfaction with genital appearance post-operatively, but satisfaction with relationships fell, although to a non-significant extent. Most other changes were in the expected direction but did not achieve significance. Transsexuals accepted for phalloplasty have very good psychological health. Tendency to further improvement is the case after phalloplasty. Depression is commoner, however, and quality of relationships declines somewhat, perhaps in consequence. Surgeons might advise partners as well as patients of realistic expectations from such surgery.

Lindqvist et al., 2017

Lindqvist, E. K., Sigurjonsson, H., Möllermark, C., Rinder, J., Farnebo, F., et al. (2017). Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery , 40 (3), 223-226.

Background: Few studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS). Methods: We performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Results: On most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined. Conclusions: To our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group. Level of evidence: Level III, therapeutic study.

Simonsen et al., 2016

Simonsen, R. K., Giraldi, A., Kristensen, E., & Hald, G. M. (2016). Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality. Nordic Journal Of Psychiatry , 70 (4), 241-247.

Background: There is a lack of long-term register-based follow-up studies of sex-reassigned individuals concerning mortality and psychiatric morbidity. Accordingly, the present study investigated both mortality and psychiatric morbidity using a sample of individuals with transsexualism which comprised 98% (n = 104) of all individuals in Denmark. Aims: (1) To investigate psychiatric morbidity before and after sex reassignment surgery (SRS) among Danish individuals who underwent SRS during the period of 1978–2010. (2) To investigate mortality among Danish individuals who underwent SRS during the period of 1978–2010.Method: Psychiatric morbidity and mortality were identified by data from the Danish Psychiatric Central Research Register and the Cause of Death Register through a retrospective register study of 104 sex-reassigned individuals. Results: Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant). A total of 6.7% of the sample were registered with psychiatric morbidity both before and after SRS. Significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth. Ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years. Conclusions: No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM) save for the total number of psychiatric diagnoses where FtM held a significantly higher number of psychiatric diagnoses overall. Despite the over-representation of psychiatric diagnoses both pre- and post-SRS the study found that only a relatively limited number of individuals had received diagnoses both prior to and after SRS. This suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.

Udeze, 2008

Udeze, B., Abdelmawla, N., Khoosal, D., & Terry, T. (2008). Psychological functions in male-to-female transsexual people before and after surgery. Sexual & Relationship Therapy , 23 (2), 141-145.

Patients with gender dysphoria (GD) suffer from a constant feeling of psychological discomfort related to their anatomical sex. Gender reassignment surgery (GRS) attempts to release this discomfort. The aim of this study was to compare the functioning of a cohort or patients with GD before and after GRS. We hypothesized that there would be an improvement in the scores of the self-administered SCL-90R following gender reassignment surgery among male-to-female people with gender dysphoria. We studied 40 patients with a DSM-IV diagnosis of Gender Identity Disorder (GID) who attended Leicester Gender Identity Clinic. We compared their functioning as measured by Symptom Check List-90R (SCL-90R) which was administered to 40 randomly selected male-to-female patients before and within six months after GRS using the same sample as control pre-and post-surgery. There was no significant change in the different sub-scales of the SCL-90R scores in patients with male-to-female GID pre- and within six months post-surgery. The results of the study showed that GRS had no significant effect on functioning as measured by SCL-90R within six months of surgery. Our study has the advantage of reducing inter-subject variability by using the same patients as their own control. This study may be limited by the duration of reassessment post-surgery. Further studies with larger sample size and using other psychosocial scales are needed to elucidate on the effectiveness of surgical intervention on psychosocial parameters in patients with GD.

Below are 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being. Click here to jump to the 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

American psychological, 2015.

Guidelines for psychological practice with transgender and gender nonconforming people. (2015). American Psychologist, 70 (9), 832-864.

In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.

Bockting et al., 2016

Bockting, W., Coleman, E., Deutsch, M. B., Guillamon, A., Meyer, W., et al. (2016). Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology & Diabetes and Obesity , 23 (2), 188–197.

Purpose of review: Research on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research. Recent findings: Pervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and well-being. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. Although there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking. Summary: Greater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

Byne et al., 2012

Byne, W., Bradley, S.J., Coleman, E., et al. (2012). Report of the American Psychiatric Association task force on treatment of gender identity disorder. Archives of Sexual Behavior, 41 (4): 759–796.

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Carroll, 1999

Carroll, R. A. (1999). Outcomes of treatment for gender dysphoria. Journal of Sex Education and Therapy , 24 (3), 128–136.

This paper reviews the empirical research on the psychosocial outcomes of treatment for gender dysphoria. Recent research has highlighted the heterogeneity of transgendered experiences. There are four possible outcomes for patients who present with the dilemma of gender dysphoria: an unresolved outcome, acceptance of one’s given gender, engaging in a cross-gender role on a part-time basis, and making a full-time transition to the other gender role. Clinical work, but not empirical research, suggests that some individuals with gender dysphoria may come to accept their given gender role through psychological treatment. Many individuals find that it is psychologically sufficient to express the transgendered part of themselves through such activities as cross-dressing or gender blending. The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive. Predictors of a good outcome include good pre-reassignment psychological adjustment, family support, at least 1 year of living in the desired role, consistent use of hormones, psychological treatment, and good surgical outcomes. The outcome literature provides strong support for adherence to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association. Implications to be drawn from this research include an appreciation of the diversity of transgendered experience, the need for more research on non-reassignment resolutions to gender dysphoria, and the importance of assisting the transgendered individual to identify the resolution that best suits him or her.

Cohen-Kettenis and Gooren, 1999

Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology, diagnosis and treatment. Journal of Psychosomatic Research , 46 (4), 315-333.

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Coleman et al., 2012

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism , 13 (4), 165-232.

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Committee on Health Care for Underserved, 2011

Committee Opinion No. 512: Health Care for Transgender Individuals. (2011). Obstetrics & Gynecology , 118 (6), 1454–1458.

Transgender individuals face harassment, discrimination, and rejection within our society. Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population. Although the care for these patients is often managed by a specialty team, obstetrician–gynecologists should be prepared to assist or refer transgender individuals with routine treatment and screening as well as hormonal and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity and urges public and private health insurance plans to cover the treatment of gender identity disorder.

Costa and Colizzi, 2016

Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatric Disease and Treatment , 12 , 1953-1966.

Cross-sex hormonal treatment represents a main aspect of gender dysphoria health care pathway. However, it is still debated whether this intervention translates into a better mental well-being for the individual and which mechanisms may underlie this association. Although sex reassignment surgery has been the subject of extensive investigation, few studies have specifically focused on hormonal treatment in recent years. Here, we systematically review all studies examining the effect of cross-sex hormonal treatment on mental health and well-being in gender dysphoria. Research tends to support the evidence that hormone therapy reduces symptoms of anxiety and dissociation, lowering perceived and social distress and improving quality of life and self-esteem in both male-to-female and female-to-male individuals. Instead, compared to female-to-male individuals, hormone-treated male-to-female individuals seem to benefit more in terms of a reduction in their body uneasiness and personality-related psychopathology and an amelioration of their emotional functioning. Less consistent findings support an association between hormonal treatment and other mental health-related dimensions. In particular, depression, global psychopathology, and psychosocial functioning difficulties appear to reduce only in some studies, while others do not suggest any improvement in these domains. Results from longitudinal studies support more consistently the association between hormonal treatment and improved mental health. On the contrary, a number of cross-sectional studies do not support this evidence. This review provides possible biological explanation vs psychological explanation (direct effect vs indirect effect) for the hormonal treatment-induced better mental well-being. In conclusion, this review indicates that gender dysphoria-related mental distress may benefit from hormonal treatment intervention, suggesting a transient reaction to the nonsatisfaction connected to the incongruent body image rather than a stable psychiatric comorbidity. In this perspective, timely hormonal treatment intervention represents a crucial issue in gender dysphoria individuals’ mental health-related outcome.

Dhejne et al., 2016

Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review Of Psychiatry , 28 (1), 44-57.

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Gijs and Brewaeys, 2007

Gijs, L., & Brewaeys, A. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges. Annual Review of Sex Research , 18 (1), 178-224.

In 1990 Green and Fleming concluded that sex reassignment surgery (SRS) is an effective treatment for transsexuality because it reduced gender dysphoria drastically. Since 1990, many new outcome studies have been published, raising the question as to whether the conclusion of Green and Fleming still holds. After describing terminological and conceptual developments related to the treatment of gender identity disorder (GID), follow-up studies, including both adults and adolescents, of the outcomes of SRS are reviewed. Special attention is paid to the effects of SRS on gender dysphoria, sexuality, and regret. Despite methodological shortcomings of many of the studies, we conclude that SRS is an effective treatment for transsexualism and the only treatment that has been evaluated empirically with large clinical case series.

Gooren, 2011

Gooren, L. J. (2011). Care of transsexual persons. New England Journal of Medicine , 364 (13), 1251–1257.

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise? A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise?

Hembree et al., 2009

Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W., et al. (2009). Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 94 (9), 3132–3154.

Objective: The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. Consensus Process: Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. Conclusions: Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person’s genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person’s desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons. Endocrine treatment of transsexual persons should include suppression of endogenous sex hormones, physiologic levels of gender-appropriate sex hormones, and suppression of puberty in adolescents (Tanner stage 2).

Michel et al., 2002

Michel, A., Ansseau, M., Legros, J., Pitchot, W., & Mormont, C. (2002). The transsexual: What about the future? European Psychiatry , 17 (6), 353-362.

Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.

Murad et al., 2010

Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology , 72 (2), 214-231.

Objective: To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self‐reported psychosocial outcomes. Methods: We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random‐effects meta‐analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between‐study heterogeneity not attributable to chance using the I2 statistic. Results: We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male‐to‐female, 801 female‐to‐male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). Conclusions: Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

Reisner et al., 2016

Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., et al. (2016). Global health burden and needs of transgender populations: A review. The Lancet , 388 (10042), 412-436.

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Schmidt and Levine, 2015

Schmidt, L., & Levine, R. (2015). Psychological Outcomes and Reproductive Issues Among Gender Dysphoric Individuals. Endocrinology and Metabolism Clinics of North America , 44 (4), 773-785.

Gender dysphoria is a condition in which a person experiences discrepancy between the natal anatomic sex and the gender he or she identifies with, resulting in internal distress and a desire to live as the preferred gender. There is increasing demand for treatment, which includes suppression of puberty, cross-sex hormone therapy, and sex reassignment surgery. This article reviews longitudinal outcome data evaluating psychological well-being and quality of life among transgender individuals who have undergone cross-sex hormone treatment or sex reassignment surgery. Proposed methodologies for diagnosis and initiation of treatment are discussed, and the effects of cross-sex hormones and sex reassignment surgery on future reproductive potential.

White Hughto and Reisner, 2016

White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health , 1 (1), 21–31.

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time. Data Sources: MEDLINE, PsycINFO, and PubMed were searched for relevant studies from inception to November 2014. Reference lists of included studies were hand searched. Results: Three uncontrolled prospective cohort studies, enrolling 247 transgender adults (180 male-to-female [MTF], 67 female-to-male [FTM]) initiating hormone therapy for the treatment of gender identity disorder (prior diagnostic term for gender dysphoria), were identified. The studies measured exposure to hormone therapy and subsequent changes in mental health (e.g., depression, anxiety) and quality of life outcomes at follow-up. Two studies showed a significant improvement in psychological functioning at 3–6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy. Conclusions: Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning. Prospective controlled trials are needed to investigate the effects of hormone therapy on the mental health of transgender people.

Share this:

clock This article was published more than  2 years ago

Opinion What I wish I’d known when I was 19 and had sex reassignment surgery

Corinna Cohn, a software developer in Indianapolis, is an officer in the Gender Care Consumer Advocacy Network.

When I was 19, I had surgery for sex reassignment , or what is now called gender affirmation surgery. The callow young man who was obsessed with transitioning to womanhood could not have imagined reaching middle age. But now I’m closer to 50, keeping a watchful eye on my 401(k), and dieting and exercising in the hope that I’ll have a healthy retirement.

In terms of my priorities and interests today, that younger incarnation of myself might as well have been a different person — yet that was the person who committed me to a lifetime set apart from my peers.

There is much debate today about transgender treatment, especially for young people. Others might feel differently about their choices, but I know now that I wasn’t old enough to make that decision. Given the strong cultural forces today casting a benign light on these matters, I thought it might be helpful for young people, and their parents, to hear what I wish I had known.

I once believed that I would be more successful finding love as a woman than as a man, but in truth, few straight men are interested in having a physical relationship with a person who was born the same sex as them. In high school, when I experienced crushes on my male classmates, I believed that the only way those feelings could be requited was if I altered my body.

This article was featured in the Opinions A.M. newsletter. Sign up here for a digest of opinions in your inbox six days a week.

It turned out that several of those crushes were also gay. If I had confessed my interest, what might have developed? Alas, the rampant homophobia in my school during the AIDS crisis smothered any such notions. Today, I have resigned myself to never finding a partner. That’s tough to admit, but it’s the healthiest thing I can do.

As a teenager, I was repelled by the thought of having biological children, but in my vision of the adult future, I imagined marrying a man and adopting a child. It was easy to sacrifice my ability to reproduce in pursuit of fulfilling my dream. Years later, I was surprised by the pangs I felt as my friends and younger sister started families of their own.

The sacrifices I made seemed irrelevant to the teenager I was: someone with gender dysphoria, yes, but also anxiety and depression. The most severe cause of dread came from my own body. I was not prepared for puberty, nor for the strong sexual drive typical for my age and sex.

Surgery unshackled me from my body’s urges, but the destruction of my gonads introduced a different type of bondage. From the day of my surgery, I became a medical patient and will remain one for the rest of my life. I must choose between the risks of taking exogenous estrogen, which include venous thromboembolism and stroke, or the risks of taking nothing, which includes degeneration of bone health. In either case, my risk of dementia is higher, a side effect of eschewing testosterone.

What was I seeking for my sacrifice? A feeling of wholeness and perfection. I was still a virgin when I went in for surgery. I mistakenly believed that this made my choice more serious and authentic. I chose an irreversible change before I’d even begun to understand my sexuality. The surgeon deemed my operation a good outcome, but intercourse never became pleasurable. When I tell friends, they’re saddened by the loss, but it’s abstract to me — I cannot grieve the absence of a thing I’ve never had.

Where were my parents in all this? They were aware of what I was doing, but by that point, I had pushed them out of my life. I didn’t need parents questioning me or establishing realistic expectations — especially when I found all I needed online. In the early 1990s, something called Internet Relay Chat, a rudimentary online forum, allowed me to meet like-minded strangers who offered an inexhaustible source of validation and acceptance.

I shudder to think of how distorting today’s social media is for confused teenagers. I’m also alarmed by how readily authority figures facilitate transition. I had to persuade two therapists, an endocrinologist and a surgeon to give me what I wanted. None of them were under crushing professional pressure, as they now would be, to “affirm” my choice.

I may well have transitioned even after waiting a few years. If I hadn’t transitioned, I likely would have suffered from the world in other ways. In other words, I’m still working out how much regret to feel, but I’m comfortable with the ambiguity.

What advice would I pass on to young people seeking transition? Learning to fit in your body is a common struggle. Fad diets, body-shaping clothing and cosmetic surgery are all signs that countless millions of people at some point have a hard time accepting their own reflection. The prospect of sex can be intimidating. But sex is essential in healthy relationships. Give it a chance before permanently altering your body.

Most of all, slow down. You may yet decide to make the change. But if you explore the world by inhabiting your body as it is, perhaps you’ll find that you love it more than you thought possible.

Opinions Newsletters

Today’s Opinions: A narrated rundown of Post Opinions’ latest pieces, sent every weekday afternoon.

The Checkup With Dr. Wen: Guidance on navigating the pandemic and other public health challenges.

The Week In Ideas: Thought-provoking opinions you may have missed.

Karen Attiah: Attiah dives into matters of personal and political liberation during times of change.

Post Elizabeth: Royal watcher Autumn Brewington shares updates on changes at the British royal palace.

Opinions Headlines: The best Opinions links, in your inbox six days a week.

Follow Alerts: Sign up to receive email notifications from your favorite columnists on our newsletters page.

• Opinion | A Trump dictatorship is increasingly inevitable. We should stop pretending. November 30, 2023 Opinion | A Trump dictatorship is increasingly inevitable. We should stop pretending. November 30, 2023
• Opinion | The Supreme Court’s Republican bias hangs over the Trump immunity case May 5, 2024 Opinion | The Supreme Court’s Republican bias hangs over the Trump immunity case May 5, 2024
• Opinion | This should be a 5-alarm fire for anyone who cares about inflation May 2, 2024 Opinion | This should be a 5-alarm fire for anyone who cares about inflation May 2, 2024

• Search Menu
• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Urban Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Literature
• Classical Reception
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Archaeology
• Greek and Roman Papyrology
• Late Antiquity
• Religion in the Ancient World
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Agriculture
• History of Education
• History of Emotions
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Acquisition
• Language Variation
• Language Families
• Language Evolution
• Language Reference
• Lexicography
• Linguistic Theories
• Linguistic Typology
• Linguistic Anthropology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Modernism)
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Religion
• Music and Culture
• Music and Media
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Science
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Lifestyle, Home, and Garden
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Politics
• Law and Society
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Neuroanaesthesia
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Oncology
• Medical Toxicology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Clinical Neuroscience
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Medical Ethics
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Security
• Computer Games
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Neuroscience
• Cognitive Psychology
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business Strategy
• Business History
• Business Ethics
• Business and Government
• Business and Technology
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic Systems
• Economic Methodology
• Economic History
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Natural Disasters (Environment)
• Social Impact of Environmental Issues (Social Science)
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• International Political Economy
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Theory
• Political Behaviour
• Political Economy
• Political Institutions
• Politics and Law
• Public Administration
• Public Policy
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Developmental and Physical Disabilities Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

• < Previous chapter
• Next chapter >

13.1 The ethics of gender reassignment surgery

• Published: August 2021
• Cite Icon Cite
• Permissions Icon Permissions

Transgender issues are very much in the news at present. There has been discussion about both gender dysphoria in general but, more specifically, the practical, psychological, and financial implications of carrying out gender reassignment surgery. In the United Kingdom, this extends to a debate on whether it is justifiable to carry out these procedures within an already hard-pressed National Health Service. This chapter discusses the nature, history, and background of both gender dysphoria and gender reassignment surgery and whether such procedures are justifiable in terms of outcomes and patient satisfaction; and also whether these are legitimate procedures to carry out within the National Health Service.

Signed in as

Institutional accounts.

• Google Scholar Indexing
• GoogleCrawler [DO NOT DELETE]

Personal account

• Sign in with email/username & password
• Get email alerts
• Save searches
• Purchase content
• Activate your purchase/trial code

Institutional access

• Sign in with a library card Sign in with username/password Recommend to your librarian
• Institutional account management
• Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Sign in through your institution

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institution’s website and Oxford Academic.

• Click Sign in through your institution.
• Select your institution from the list provided, which will take you to your institution's website to sign in.
• When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
• Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institution’s website, please contact your librarian or administrator.

Sign in with a library card

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see ‘Sign in through society site’ in the sign in pane within a journal:

• Click Sign in through society site.
• When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

• View your signed in personal account and access account management features.
• View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Rights and permissions
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Articles on Gender reassignment surgery

Displaying all articles.

Friday essay: ‘I hope eventually to become a woman’ – trans life in Australia from the 1940s to 1970s

Noah Riseman , Australian Catholic University

I’m a pediatrician who cares for transgender kids – here’s what you need to know about social support, puberty blockers and other medical options that improve lives of transgender youth

Mandy Coles , Boston University

Surgery to make intersex children ‘normal’ should be banned

Cornelia Koch , University of Adelaide and Travis Wisdom , University of Adelaide

Related Topics

• Friday essay
• Male circumcision
• Mental health
• Transgender
• Transgender health
• transgender women
• Trans youth 2021

Top contributors

Senior Lecturer in Law, University of Adelaide

PhD Candidate, International Human Rights Law, University of Adelaide

Clinical Associate Professor of Pediatrics and co-director of the Child and Adolescent Trans/Gender Center for Health, Boston University

Professor in History, Australian Catholic University

• X (Twitter)
• Unfollow topic Follow topic

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Review Article
• Published: 02 June 2020

Urethral complications after gender reassignment surgery: a systematic review

• N. Nassiri 1 ,
• M. Maas   ORCID: orcid.org/0000-0001-9677-9917 1 ,
• M. Basin 1 ,
• G. E. Cacciamani 1 &
• L. R. Doumanian 1  

International Journal of Impotence Research volume  33 ,  pages 793–800 ( 2021 ) Cite this article

1061 Accesses

22 Citations

56 Altmetric

Metrics details

• Health care
• Medical research

The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms ((“Transsexualism”[Mesh])) AND (“Sex Reassignment Surgery”[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19–54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

This is a preview of subscription content, access via your institution

Access options

Subscribe to this journal

Receive 8 print issues and online access

251,40 € per year

only 31,43 € per issue

Buy this article

• Purchase on Springer Link
• Instant access to full article PDF

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Polycystic ovary syndrome

Male delayed orgasm and anorgasmia: a practical guide for sexual medicine providers

Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement

Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nat Rev Urol. 2011;8:274–82. https://doi.org/10.1038/nrurol.2011.46 .

Article   PubMed   Google Scholar  

Santucci RA. Urethral complications after transgender phalloplasty: strategies to treat them and minimize their occurrence. Clin Anat 2018;31:187–90. https://doi.org/10.1002/ca.23021 .

Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097. https://doi.org/10.1371/journal.pmed.1000097 .

Article   PubMed   PubMed Central   Google Scholar  

Oxford Center of Evidence-Based Medicine. Levels of Evidence. https://www.cebm.net/2016/05/ocebm-levels-of-evidence/ . Published 2011. Accessed September 22, 2019.

Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47:398–402. https://doi.org/10.1016/j.eururo.2004.10.008 .

Weyers S, Selvaggi G, Monstrey S, et al. Two-stage versus one-stage sex reassignment surgery in female-to-male transsexual individuals. Gynecol Surg. 2006;3:190–4. https://doi.org/10.1007/s10397-006-0203-3 .

Article   Google Scholar  

Schaff J. Enlarged range of free flaps for phalloplasty in transsexual reassignment surgery. Int J Transgenderism. 2007;10:39–45. https://doi.org/10.1300/J485v10n01_06 .

Takamatsu A, Harashina T. Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:318–25. https://doi.org/10.1016/j.bjps.2008.11.038 .

Article   CAS   PubMed   Google Scholar  

Kim S-K, Lee K-C, Kwon Y-S, Cha B-H. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:309–17. https://doi.org/10.1016/j.bjps.2007.11.011 .

Zhang Y-F, Liu C-Y, Qu C-Y, et al. Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals? World J Urol. 2015;33:2115–23. https://doi.org/10.1007/s00345-015-1562-z .

Fang R-H, Kao Y-S, Ma S, Lin J-T. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52:217–22. https://doi.org/10.1054/bjps.1998.3027 .

Dabernig J, Chan LKW, Schaff J. Phalloplasty with free (septocutaneous) fibular flap sine fibula. J Urol 2006;176:2085–8. https://doi.org/10.1016/j.juro.2006.07.036 .

Djordjevic ML, Stanojevic D, Bizic M, et al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;6:1306–13. https://doi.org/10.1111/j.1743-6109.2008.01065.x .

Garaffa G, Christopher NA, Ralph DJ. Total phallic construction in female to male transsexuals. Curr Urol 2009;3:146–55. https://doi.org/10.1159/000253373 .

Kim S-K, Moon J-B, Heo J, Kwon Y-S, Lee K-C. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64:759–64. https://doi.org/10.1097/SAP.0b013e3181a5b719 .

Wierckx K, Van Caenegem E, Elaut E, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8:3379–88. https://doi.org/10.1111/j.1743-6109.2011.02348.x .

Djordjevic ML, Bizic MR. Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013;10:1431–8. https://doi.org/10.1111/jsm.12108 .

van der Sluis WB, Smit JM, Pigot GLS, et al. Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction. Microsurgery 2017;37:917–23. https://doi.org/10.1002/micr.30190 .

Stojanovic B, Bizic M, Bencic M, et al. One-stage gender-confirmation surgery as a viable surgical procedure for female-to-male transsexuals. J Sex Med. 2017;14:741–6. https://doi.org/10.1016/j.jsxm.2017.03.256 .

Al-Tamimi M, Pigot GL, van der Sluis WB, et al. Colpectomy significantly reduces the risk of urethral fistula formation after urethral lengthening in transgender men undergoing genital gender affirming surgery. J Urol 2018;200:1315–21. https://doi.org/10.1016/j.juro.2018.07.037 .

Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. J Urol 2018;199:206–14. https://doi.org/10.1016/j.juro.2017.07.084 .

Wirthmann AE, Majenka P, Kaufmann MC, et al. Phalloplasty in female-to-male transsexuals by Gottlieb and Levine’s free radial forearm flap technique-A long-term single-center experience over more than two decades. J Reconstr Microsurg. 2018;34:235–41. https://doi.org/10.1055/s-0037-1608656 .

Namba Y, Watanabe T, Kimata Y. Flap combination phalloplasty in female-to-male transsexuals. J Sex Med. 2019;16:934–41. https://doi.org/10.1016/j.jsxm.2019.02.010 .

D’Arpa S, Claes K, Lumen N, et al. Urethral reconstruction in anterolateral thigh flap phalloplasty: a 93-case experience. Plast Reconstr Surg. 2019;143:382e–392e. https://doi.org/10.1097/PRS.0000000000005278 .

Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal colpectomy in transgender men: a retrospective cohort study on surgical procedure and outcomes. J Sex Med. 2019. https://doi.org/10.1016/j.jsxm.2019.03.263 .

Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44:611–4. https://doi.org/10.1016/S0302-2838(03)00356-7 .

Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol 2010;57:715–22. https://doi.org/10.1016/j.eururo.2009.05.018 .

Lawrence AA. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Arch Sex Behav. 2006;35:717–27. https://doi.org/10.1007/s10508-006-9104-9 .

Rossi Neto R, Hintz F, Krege S, Rübben H, vom Dorp F. Gender reassignment surgery - a 13 year review of surgical outcomes. Int Braz J Urol. 2012;38:97–107. https://doi.org/10.1590/S1677-55382012000100014 .

Amend B, Seibold J, Toomey P, Stenzl A, Sievert K-D. Surgical reconstruction for male-to-female sex reassignment. Eur Urol 2013;64:141–9. https://doi.org/10.1016/j.eururo.2012.12.030 .

Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. 2015;12:1837–45. https://doi.org/10.1111/jsm.12936 .

van der Sluis WB, Bouman M-B, de Boer NKH, et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med. 2016;13:702–10. https://doi.org/10.1016/j.jsxm.2016.01.008 .

Kuzon WMJ, Gast KM, Buncamper ME, et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast Reconstr Surg. 2016;138:999–1007. https://doi.org/10.1097/PRS.0000000000002684 .

Article   CAS   Google Scholar  

Ives GC, Fein LA, Finch L, et al. Evaluation of BMI as a risk factor for complications following gender-affirming penile inversion vaginoplasty. Plast Reconstr Surg Glob Open. 2019;7:e2097 https://doi.org/10.1097/GOX.0000000000002097 .

Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int. 2007;100:607–13. https://doi.org/10.1111/j.1464-410X.2007.07017.x .

Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. 2001;88:396–402. https://doi.org/10.1046/j.1464-410X.2001.02323.x .

World Professional Association for Transgender Health. Standards of Care—WPATH. https://www.wpath.org/publications/soc . Accessed September 25, 2019.

Morrison SD, Chen ML, Crane CN. An overview of female-to-male gender-confirming surgery. Nat Rev Urol. 2017;14:486–500. https://doi.org/10.1038/nrurol.2017.64 .

Jun MS, Santucci RA. Urethral stricture after phalloplasty. Transl Androl Urol. 2019;8:266–72. https://doi.org/10.21037/tau.2019.05.08 .

Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with urethral lengthening: addition of a vascularized bulbospongiosus flap from vaginectomy reduces postoperative urethral complications. Plast Reconstr Surg. 2017;140:551e–558e. https://doi.org/10.1097/PRS.0000000000003697 .

Salgado CJ, Nugent AG, Moody AM, Chim H, Paz AM, Chen H-C. Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula. J Plast Reconstr Aesthet Surg. 2016;69:1551–7. https://doi.org/10.1016/j.bjps.2016.05.011 .

Cocci A, Frediani D, Cacciamani GE, et al. Systematic review of studies reporting perioperative and functional outcomes following male-to- female gender assignment surgery (MtoF GAS): a call for standardization in data reporting. Minerva Urol Nefrol. 2019. https://doi.org/10.23736/S0393-2249.19.03407-6 .

Download references

There was no funding source for this study. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Author information

Authors and affiliations.

Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA

N. Nassiri, M. Maas, M. Basin, G. E. Cacciamani & L. R. Doumanian

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to L. R. Doumanian .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Prisma 2009 checklist, rights and permissions.

Reprints and permissions

About this article

Cite this article.

Nassiri, N., Maas, M., Basin, M. et al. Urethral complications after gender reassignment surgery: a systematic review. Int J Impot Res 33 , 793–800 (2021). https://doi.org/10.1038/s41443-020-0304-y

Download citation

Received : 15 February 2020

Revised : 20 April 2020

Accepted : 05 May 2020

Published : 02 June 2020

Issue Date : December 2021

DOI : https://doi.org/10.1038/s41443-020-0304-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Phalloplasty and metoidioplasty: a systematic review of sensation, orgasm, and penetrative intercourse.

• Elad Fraiman
• Kelly Chambers
• Shubham Gupta

Current Sexual Health Reports (2023)

Imaging in Gender Affirmation Surgery

• Omar Hassan
• Priyanka Jha

Current Urology Reports (2021)

Geschlechtsangleichung von Frau zu Mann

• S. Morgenstern

Der Urologe (2020)

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Supplements
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

See More About

Sign up for emails based on your interests, select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Download PDF
• X Facebook More LinkedIn

Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

Manage citations:

© 2024

• Permissions

National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• Share full article

Advertisement

Supported by

My New Vagina Won’t Make Me Happy

And it shouldn’t have to.

By Andrea Long Chu

Ms. Chu is an essayist and critic.

Next Thursday, I will get a vagina. The procedure will last around six hours, and I will be in recovery for at least three months. Until the day I die, my body will regard the vagina as a wound; as a result, it will require regular, painful attention to maintain. This is what I want, but there is no guarantee it will make me happier. In fact, I don’t expect it to. That shouldn’t disqualify me from getting it.

I like to say that being trans is the second-worst thing that ever happened to me. (The worst was being born a boy .) Dysphoria is notoriously difficult to describe to those who haven’t experienced it, like a flavor. Its official definition — the distress some transgender people feel at the incongruence between the gender they express and the gender they’ve been socially assigned — does little justice to the feeling.

But in my experience, at least: Dysphoria feels like being unable to get warm, no matter how many layers you put on. It feels like hunger without appetite. It feels like getting on an airplane to fly home, only to realize mid-flight that this is it: You’re going to spend the rest of your life on an airplane. It feels like grieving. It feels like having nothing to grieve.

Many conservatives call this crazy. A popular right-wing narrative holds that gender dysphoria is a clinical delusion; hence, feeding that delusion with hormones and surgeries constitutes a violation of medical ethics. Just ask the Heritage Foundation fellow Ryan T. Anderson, whose book “When Harry Became Sally” draws heavily on the work of Dr. Paul McHugh, the psychiatrist who shut down the gender identity clinic at Johns Hopkins in 1979 on the grounds that trans-affirmative care meant “cooperating with a mental illness.” Mr. Anderson writes, “We must avoid adding to the pain experienced by people with gender dysphoria, while we present them with alternatives to transitioning.”

In this view, it is not only fair to refuse trans people the care they seek; it is also kind . A therapist with a suicidal client does not draw the bath and supply the razor. Take it from my father, a pediatrician, who once remarked to me that he would no sooner prescribe puberty blockers to a gender dysphoric child than he would give a distemper shot to someone who believed she was a dog.

Naturally, a liberal counternarrative exists, and it has become increasingly mainstream. Transgender people are not deluded, advocates say, but they are suffering; therefore, medical professionals have a duty to ease that suffering. In this view, dysphoria is more akin to a herniated disc — a source of debilitating but treatable pain. “Gender dysphoria can in large part be alleviated through treatment,” states the World Professional Association for Transgender Health in its Standards of Care. Dr. John Steever, an adolescent medicine specialist at the Mount Sinai Center for Transgender Medicine and Surgery in New York City, told The Times last month that a gender-affirming approach seeks to “prevent some of the traditional horrible outcomes that transgender or gender-nonconforming youth have ended up with,” including increased rates of depression, suicidal ideation and substance abuse.

A gender-affirmative model will almost certainly lead to more and higher-quality care for transgender patients. But by focusing on minimizing patients’ pain, it leaves the door open for care to be refused when a doctor, or someone playing doctor, deems the risks too high. This was the thrust of a recent Atlantic cover story in which the journalist Jesse Singal used the statistically small number of people who have come to regret their medical transitions to argue that transitioning is “not the answer for everyone.” There was a dog whistle here: Hormones and surgery can and should be withheld from patients who want them when such treatments cannot be reasonably expected to “maximize good outcomes.”

Mr. Singal is Mr. Anderson’s liberal doppelgänger. Both writers engage in what we could call “compassion-mongering,” peddling bigotry in the guise of sympathetic concern. Both posit a medical duty to refrain from increasing trans people’s suffering — what’s called nonmaleficence. Neither has any issue with gatekeeping per se; they differ, modestly, on how the gate is to be kept.

Buried under all of this, like a sober tuber , lies an assumption so sensible you’ll think me silly for digging it up. It’s this: People transition because they think it will make them feel better. The thing is, this is wrong.

I feel demonstrably worse since I started on hormones. One reason is that, absent the levees of the closet , years of repressed longing for the girlhood I never had have flooded my consciousness. I am a marshland of regret. Another reason is that I take estrogen — effectively, delayed-release sadness, a little aquamarine pill that more or less guarantees a good weep within six to eight hours.

Like many of my trans friends, I’ve watched my dysphoria balloon since I began transition. I now feel very strongly about the length of my index fingers — enough that I will sometimes shyly unthread my hand from my girlfriend’s as we walk down the street. When she tells me I’m beautiful, I resent it. I’ve been outside. I know what beautiful looks like. Don’t patronize me.

I was not suicidal before hormones. Now I often am.

I won’t go through with it, probably. Killing is icky. I tell you this not because I’m cruising for sympathy but to prepare you for what I’m telling you now: I still want this, all of it. I want the tears; I want the pain. Transition doesn’t have to make me happy for me to want it. Left to their own devices, people will rarely pursue what makes them feel good in the long term. Desire and happiness are independent agents.

As long as transgender medicine retains the alleviation of pain as its benchmark of success, it will reserve for itself, with a dictator’s benevolence, the right to withhold care from those who want it. Transgender people have been forced, for decades, to rely for care on a medical establishment that regards them with both suspicion and condescension. And yet as things stand today, there is still only one way to obtain hormones and surgery: to pretend that these treatments will make the pain go away.

The medical maxim “First, do no harm” assumes that health care providers possess both the means and the authority to decide what counts as harm. When doctors and patients disagree, the exercise of this prerogative can, itself, be harmful. Nonmaleficence is a principle violated in its very observation. Its true purpose is not to shield patients from injury but to install the medical professional as a little king of someone else’s body.

Let me be clear: I believe that surgeries of all kinds can and do make an enormous difference in the lives of trans people.

But I also believe that surgery’s only prerequisite should be a simple demonstration of want. Beyond this, no amount of pain, anticipated or continuing, justifies its withholding.

Nothing, not even surgery, will grant me the mute simplicity of having always been a woman. I will live with this, or I won’t. That’s fine. The negative passions — grief, self-loathing, shame, regret — are as much a human right as universal health care, or food. There are no good outcomes in transition. There are only people, begging to be taken seriously.

Andrea Long Chu is an essayist and a critic. Her book “Females: A Concern” is forthcoming.

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study

Affiliations.

• 1 From the Department of Plastic and Reconstructive Surgery.
• 2 School of Medicine.
• 3 Department of Obstetrics and Gynecology.
• 4 Department of Urology.
• 5 Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA.
• PMID: 36149983
• DOI: 10.1097/SAP.0000000000003233

Background: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes.

Methods: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared.

Results: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.

Conclusion: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

• Follow-Up Studies
• Gender Dysphoria* / surgery
• Sex Reassignment Surgery*
• Transgender Persons* / psychology
• Transsexualism* / psychology

Outlawing Trans Youth: State Legislatures and the Battle over Gender-Affirming Healthcare for Minors

Chapter One

• See full issue

As soon as I realized that I was not happy in my body, I went up to my parents to fix it. And it felt as natural as going up and being like, “Hey, I’m hungry.” I was just kind of like, “Hey, when’s the girl thing happening? ”

— Nicole Maines, actress and transgender activist, on coming out as transgender as a child 1

More than one-third of transgender high school students attempt suicide in a given year. 2 This alarming statistic underscores the importance of providing transgender youth 3 with access to medically necessary healthcare to bring their bodies into alignment with their gender identities. 4 Fortunately, medical science and understanding have advanced such that trans youth can safely and effectively transition under the supervision of medical professionals. 5 Obstacles remain, to be sure. 6 But information about, and access to, gender-affirming care for trans youth is more widespread than ever before. 7

Over the last few years, however, a growing political tide has threatened to reverse this progress. Gender-affirming healthcare 8 for minors has become a new frontier in the culture war. In the first months of 2020 alone, legislators in at least fifteen states introduced bills that would have prohibited and, in many cases, criminalized providing gender-affirming healthcare services to minors. 9 None of these bills became law. 10 But the fight over gender-affirming healthcare for minors is far from over; as of January 2021, at least nine states were considering gender-affirming care bans, 11 with more sure to follow, and a recent court decision in the United Kingdom effectively banning hormone treatments for trans youth under sixteen is likely to embolden the stateside opposition even further. 12 This Chapter shines light on attempts to outlaw necessary gender-affirming medical treatment for minors, drawing on scientific evidence and legal doctrine to show why such legislative efforts are harmful, prejudiced, and unconstitutional. Section A will outline the current medical standard of care for trans youth and argue that access to gender-affirming care provides critical and empirically demonstrable psychological, social, and legal benefits for trans youth. Section B will describe the 2020 bills, 13 critique their foundational premises, and analyze how their paternalistic narratives represent new rhetorical strategies of opposition to trans youth. Section C will offer two constitutional arguments against the bans, one based in the Equal Protection Clause and one based in parental due process rights.

The Importance of Gender-Affirming Healthcare for Trans Youth

The prevalence and availability of gender-affirming healthcare for trans youth have increased considerably since the 1990s, when transitioning before adulthood was quite rare. 14 A 2017 survey found that almost two percent of American public high school students in ten states and nine large urban school districts identified as transgender, 15 and although not all trans youth seek out gender-affirming healthcare, exponentially greater numbers of trans youth are pursuing this care. 16 This section describes the current medical standard of gender-affirming healthcare for trans youth and explains the importance of gender-affirming healthcare to the mental and social well-being and legal recognition of trans youth.

1. The Current Standard of Care.

The purpose of gender-affirming healthcare is usually to treat gender dysphoria (“dysphoria”), or “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth.” 17 Physical and social transition through the use of gender-affirming healthcare is clinically shown to reduce dysphoria by aligning a transgender person’s physical body and gender presentation with their gender identity. 18 Thus, every major U.S. medical association recognizes that gender-affirming healthcare is medically necessary treatment for dysphoria. 19

Gender-affirming healthcare for trans youth is typically admin-istered pursuant to Standards of Care published by the World Professional Association for Transgender Health (WPATH SOC), an international body of experts in transgender healthcare. 20 The WPATH SOC represent the authoritative medical consensus on treatment for dysphoria in transgender people. 21

The first step in gender-affirming treatment for trans youth is therapy and counseling. The WPATH SOC recommend that trans youth be diagnosed with gender dysphoria and referred by a gender therapist before they begin physical transition. 22 After the initial diagnosis, gender-affirming therapists help trans youth process their gender identities and cope with distress associated with dysphoria and coexisting sources of stress, and support them in taking future steps in physical and social transition. 23

Trans youth who are diagnosed with dysphoria sometimes begin hormone treatments, depending on their age and stage of physical development. Trans youth who have reached the early stages of puberty may be prescribed puberty blockers, which prevent the further progression of assigned-sex puberty and the development of associated secondary sex characteristics. 24 Halting puberty is typically done to give trans youth more time to process their identity and decide whether to pursue further steps in transition, 25 and to prevent irreversible physical changes that conflict with their desired gender presentation and increase dysphoria. 26

Beginning at around age sixteen, 27 trans youth can be prescribed hormone replacement therapy (HRT), which causes development of secondary sex characteristics associated with the trans youth’s identified gender. 28 For trans girls, HRT involves suppressing endogenous testosterone and taking estrogen, 29 a regimen that typically causes breast growth, softer skin, and reduction in body hair, 30 while for trans boys, it involves taking testosterone, 31 which typically causes muscle growth, an increase in body and facial hair, and a deeper voice. 32 Some nonbinary youth also seek HRT, but there are currently no formal standards of care for nonbinary people and there is little research as to clinical outcomes outside the binary context. 33 The WPATH SOC and Endocrine Society typically require parental consent before doctors may prescribe HRT to minors. 34

Gender confirmation surgery (GCS), which involves changing a transgender person’s reproductive anatomy to the anatomy usually associated with their identified gender, is rarely performed for trans youth because the WPATH SOC require the patient to have attained the age of majority to be eligible for surgery. 35 Additionally, insurance coverage usually requires GCS patients to be eighteen or older. 36 However, GCS is not the only type of gender-affirming surgery. Transgender men may undergo surgery to remove breast tissue (“top surgery”), and the WPATH SOC allow this surgery to be performed on patients under eighteen on a case-by-case basis. 37

2. Why Trans Youth Need Access to Gender-Affirming Healthcare .

Access to these gender-affirming healthcare services is essential — even lifesaving — for trans youth. There is a vast disparity in traditional measures of quality of life between trans youth with untreated dysphoria and their cisgender peers. A wealth of empirical research confirms that, although it does not erase this gap, medical transition narrows it considerably. This section summarizes the benefits of gender-affirming care for trans youth in three spheres: mental health, social acceptance, and legal rights. Although they are categorized separately for organizational purposes, these spheres often intersect and complement one another in practice.

(a) Mental Health. — Untreated dysphoria in trans youth is associated with severe mental health problems, including depression, social anxiety, and suicidal thoughts and behavior. 38 A study of baseline (pre-transition) psychological characteristics of trans youth revealed that twenty percent had “moderate to extreme” depressive symptoms, and that their reported rate of suicidal thoughts and attempts was at least three times higher than that of the general youth population. 39 Over half reported having thought about suicide, and a third reported at least one attempt. 40

Conversely, a large body of research demonstrates that trans youth who receive gender-affirming healthcare to treat their dysphoria show decreased anxiety, depression, suicidal behavior, and psychological distress, 41 and increased quality of life. 42 Trans children who are allowed to socially transition before puberty have relatively normal rates of depression and anxiety, “in striking contrast” with nontransitioned trans children. 43 A longitudinal study of trans adolescents before and after they received gender-affirming care found that psychological functioning steadily improved throughout treatment and that overall well-being after treatment was “comparable to [that of] same-age peers.” 44 And a study of transgender adults found that subjects who had received puberty blockers in childhood had a significantly lower incidence of suicidal ideation than did those who had wanted puberty blockers but did not receive them. 45 Of course, gender dysphoria is not the sole cause of psychological distress and mental health problems in trans youth, nor is access to gender-affirming healthcare a panacea. But, in the words of the preeminent professional association of pediatric psychiatry in the United States, “[r]esearch consistently demonstrates that gender diverse youth . . . have better mental health outcomes” when they have access to gender-affirming healthcare. 46

(b) Social Integration. — Middle school and high school are stressful for many young people, but they are often particularly difficult social environments for trans youth. Not only are trans students disproportionately bullied and alienated by their peers, 47 but they may also have problems fitting in due to the frequent mental health issues associated with untreated dysphoria 48 and feelings of not “belonging” with cisgender students. 49 This trauma only intensifies with the onset of assigned-sex puberty, which causes trans youth to develop secondary sex characteristics (such as breasts in trans boys and facial hair in trans girls) that are inconsistent with their gender identities. 50 Because of this process, trans youth who undergo assigned-sex puberty often experience decreased self-esteem and increased body image issues, which can cause further social and educational impairment. 51 Physical changes from puberty may also make it harder for trans youth to “pass” as the gender with which they identify, 52 meaning they are more likely to experience psychological problems 53 and to face discrimination and abuse. 54

Puberty blockers and HRT allow trans youth to avoid many of these challenges. Trans youth who start puberty blockers or HRT in childhood or adolescence are spared the hardships of navigating school and peer relationships while presenting as a gender with which they do not identify. Because of this relief, medically transitioned trans youth are often more confident and socially well-adjusted than their nontransitioned peers. 55 Undergoing medical transition at an earlier age also allows many trans youth to “pass” more easily as their identified gender, 56 and avoid many of the challenges associated with being visibly transgender. 57

(c) Legal Status. — Gender-affirming medical care often mediates the availability of legal rights and protections for trans youth. Most notably, many states require medical evidence like a diagnosis of gender dysphoria, HRT, or GCS to change a transgender person’s gender on identity documents such as driver’s licenses and birth certificates. 58 Misalignment between a trans youth’s gender presentation and their gender on identity documents is not an isolated indignity; it can have serious collateral consequences. For example, many colleges and universities do not allow students to use their preferred names or genders in school records if they have not legally changed them on identity documents. 59

Access to gender-affirming care is also critical for many trans youth to participate in competitive school sports. The National Collegiate Athletic Association and some state high school athletic associations allow trans girls to play on girls’ sports teams only after they have taken HRT for a certain period, out of concern that their assigned sex gives them an “unfair” advantage. 60 Trans boys typically do not have to meet specific medical criteria in order to play on boys’ teams, 61 but in practice it will often be difficult for trans boys to compete with other boys without the physiological benefits of testosterone. 62

Finally, lack of access to gender-affirming care continues to mitigate trans youths’ access to sex-segregated school bathrooms and locker rooms. The Biden Administration is expected to reinstate the Obama Administration’s 2016 Title IX guidance that required schools to allow students to use facilities consistent with their gender identities. 63 Even so, there are reasons to think access to gender-affirming medical care is still relevant to determining trans youths’ access to such facilities. First, trans youth may be less comfortable coming out as transgender to their peers and school officials if they have not started medical transition. Second, school districts and courts may be more willing to accept in practice a trans student’s use of facilities consistent with their identified gender if they have provided evidence of being diagnosed with dysphoria or undergoing gender-affirming medical treatment. 64

Proposed State Legislation Banning Gender-Affirming Healthcare for Trans Youth

1. background and legislative context..

A custody battle in a Dallas suburb is an unlikely spark for a political brushfire. But in October 2019, a dispute in Texas family court over parental rights for a seven-year-old transgender girl ignited outrage in conservative circles. 65 The girl’s father, Jeffrey Younger, petitioned for full custody based on his disagreement with her mother’s gender-affirming parenting approach, accusing the mother of “emotional abuse” for allowing the girl to express her gender identity. 66 Unfolding amid a frenzy of media coverage and vocal opposition to the mother’s gender-affirming stance from conservatives, 67 the Younger case shined a national spotlight on the issue of gender-affirming medical care for minors and prompted calls for legislative action from Texas Republicans. 68

In truth, the Younger case and the ensuing media controversy did not begin the political movement against gender-affirming healthcare for minors so much as add fuel to a campaign already broiling within conservative lobbying groups. The Heritage Foundation, one of the most influential conservative think tanks in the United States, 69 hosted a series of events on the “medical risks” of gender-affirming healthcare for trans youth at its DC headquarters throughout 2019. 70 These events proved foundational to later legislative efforts; attendees at the conferences authored several of the bans, 71 and a policy manager at Family Policy Alliance, a Christian conservative lobbying group that cohosted one of the Heritage events, confirmed that her organization “work[ed] with legislators all over the country” to distribute “model” gender-affirming care bans to be introduced during states’ 2020 legislative sessions. 72

With help from these groups, legislators in fifteen states introduced bills between January and March 2020 banning medical professionals from providing gender-affirming healthcare to minors. 73 The bills are tellingly similar in substance and language. 74 Almost every bill (with some minor deviations 75 ) bans all medical professionals in the state from administering puberty blockers or HRT to, or performing gender-affirming surgery on, anyone under the age of eighteen, with notable exceptions for minors with “medically verifiable” developmental disorders or intersex conditions. 76 Most of the proposals make providing gender-affirming care a crime; on the extreme end, violation of Idaho’s prohibition is a felony punishable by a life sentence. 77 Because they would prevent any state-licensed medical providers from administering gender-affirming care, the bans would effectively prohibit trans youth from accessing that care unless they were able to travel out of state. Thus, they would disproportionately burden trans youth from disadvantaged socioeconomic backgrounds and communities of color, who are less likely to have the resources to travel across state lines or to relocate for care. 78

None of the fifteen bills introduced in early 2020 became law, 79 al-though bills in Alabama and South Dakota passed by large margins in individual state houses. 80 But the fact that no bills passed during the 2020 legislative session may not be a meaningful indication of whether they will pass in the future. The COVID-19 lockdowns in the United States in March 2020 forced many state legislatures to adjourn regular sessions before important committee votes on the bills. 81 Additionally, a wave of early failures does not necessarily rule out future success; “bathroom bills” banning trans people from using public bathrooms and changing facilities consistent with their identified genders failed in at least ten states between 2013 and 2015 82 before North Carolina infamously passed House Bill 2 in March 2016. 83 Finally, a recent High Court decision in the United Kingdom severely inhibiting administration of puberty blockers to trans youth under age sixteen is likely to invigorate opponents of gender-affirming care for trans youth in the United States. 84

2. Explaining Gender-Affirming Healthcare Bans.

Legal and political battles over gender-affirming healthcare have persisted for decades, 85 and are somewhat ubiquitous today. 86 Nevertheless, the gender-affirming care bans deserve particular attention because they mark a subtle yet important rhetorical pivot in the broader political opposition to trans youth. To understand the larger sociopolitical significance of the gender-affirming care bans, as well as to lay the foundation for constitutional arguments against them, this section deconstructs the bans’ underlying purposes and rationales.

Some of the bills included statements of legislative purpose that provide useful starting points. For example, the Mississippi Senate bill’s “Legislative findings and intent” section states in part that “the decision to pursue [gender-affirming care] should not be presented to or determined for minors who are incapable of comprehending the negative implications and life-altering difficulties attending to these interventions.” 87 Similar language subsists throughout the proposals, revealing a consistent, surface-level legislative intent to “protect” trans youth from gender-affirming medical interventions. 88

This paternalistic rhetoric represents a narrative shift that has surfaced in the wake of widespread rejection of preexisting justifications for discrimination against trans youth. The most prominent political crusade against trans youth, the bathroom scare of the mid-to-late 2010s, portrayed trans youth as predatory, deviant, and mentally unstable, 89 and their rights to use sex-segregated spaces as intrusions on the privacy and safety of cisgender children. 90 These strategies have largely failed both in courts of law 91 and in the court of public opinion. 92 Even many conservatives have cautioned that overt fearmongering about trans people intruding on others in public spaces is not a winning political strategy. 93

But prejudice dies hard. When one justification for negative treatment of a disfavored group falls out of favor with the public or the legal system, opponents of that group often translate their prejudice into new rhetorical forms that are more palatable. 94 The shift from the stigmatization and vilification of trans youth in the bathroom bills to the victimization narrative embodied in the gender-affirming care bans illustrates how opponents of trans identity are adapting their rhetoric in response to changing legal and social attitudes towards transgender children. Courts, media, and the public should not be fooled. The paternalistic arguments underlying gender-affirming care bans reflect the same underlying prejudices arising from the same individuals and groups, 95 and are directed towards the same ends — erasing trans youth by stigmatizing transgender identity and fortifying the gender binary 96 — as bathroom bills and similar transparently vindictive campaigns. In translating their hostility to trans youth into a more socially acceptable language of “protecting” trans youth from the supposedly fraught choice of whether to transition, 97 cultural conservatives play both sides of the ball. They moderate their image by appealing to fundamental paternalistic impulses while continuing to work toward eradication of transgender identity in children by blocking access to medical services that make transition possible. 98

Their pretextual nature does not — as the UK case illustrated 99 — mean the paternalistic justifications can be ignored. The argument that trans youth should not receive gender-affirming medical care must be vigorously discredited on its own terms as a fallacious rationalization of ingrained prejudices that contradicts both empirical data and the experiences of thousands of children. For one thing, the bills’ central justification, that trans youth lack the capacity for self-reflection necessary to accurately perceive their gender identities, 100 is flatly untrue. Trans youth are quite secure in their gender identities by the time hormonal interventions become physiologically appropriate. 101 A related claim, that trans youth should have to wait until adulthood to transition because many young children who display gender nonconforming behavior “desist,” or do not grow up to be transgender, 102 has questionable empirical support 103 and, more fundamentally, equivocates gender expression with gender identity. There is a meaningful difference between a child who exhibits gender-atypical behavior and a child who persistently identifies as another gender, and the fact that the former child may not be transgender does nothing to invalidate the latter child’s entitlement to access medically necessary gender-affirming care. And gender nonconforming children who later “desist” from expressing the binary gender opposite to their assigned sex may not necessarily identify as cisgender; they may be nonbinary or possess another gender identity. Presuming that all of these persons are cisgender thus erases nonbinary experiences. 104 Second, the implied premise that trans youth have unilateral control over whether and when they transition is empirically untrue because the current standards of care recommend both parental consent and a medical diagnosis of gender dysphoria before a minor can receive puberty blockers or HRT. 105 This “gatekeeping” model, far from uncritically acceding to trans youths’ wishes, privileges caution and deliberation over ease of access. 106 Finally, even if one accepts that a certain number of cisgender youth will mistakenly transition if gender-affirming healthcare is available (which is itself a dubious proposition), that number is likely dwarfed by the number of trans youth who will suffer the opposite, equivalent harm — being unable to transition even though transition is right for them — if gender-affirming healthcare is not available.

Constitutional Arguments Against Gender-Affirming Care Bans

Gender-affirming care bans are not only harmful and founded on false premises, they are also unconstitutional. This section sketches two constitutional arguments against these proposed bans: one based in the Equal Protection Clause of the Fourteenth Amendment, and one based in the parental rights strand of substantive due process jurisprudence.

1. Equal Protection.

The Equal Protection Clause ensures the right of all citizens to enjoy “the equal protection of the laws,” 107 or to be free from unjustified, government-imposed discrimination. 108 An equal protection challenge against a facially discriminatory law usually proceeds in two stages: First, the plaintiff must show that the law discriminates or classifies based on the plaintiff’s membership in a protected class. 109 Second, the burden shifts to the government to show that the classification is justified by an adequate government interest, and the extent of the government’s burden depends on the tier of scrutiny applied to the type of classification at issue. 110

(a) Protected Class. — In the last few years, a growing number of courts of appeals have found that discrimination against transgender people violates equal protection. 111 Some courts have held that transgender status is a protected class in its own right, 112 while others have found that antitransgender discrimination is sex discrimination. 113 Across-the-board bans on gender-affirming healthcare for trans youth would likely receive heightened scrutiny under either framing. Gender-affirming care bans discriminate based on transgender status because they prohibit providing HRT and GCS to minors for the specific purpose of affirming a trans youth’s gender identity, thus facially discriminating against transgender identity, and because in most cases they include exceptions allowing that same care to be provided to cisgender minors for the purpose of treating intersex conditions or “disorder[s] of sexual development.” 114 It may be argued that the bans do not facially discriminate based on transgender status, because they simply bar conduct associated with being transgender . But this formalistic status/conduct distinction was hardly convincing in the context of sexual orientation discrimination and is similarly unpersuasive in the context of antitransgender discrimination. 115

The per se transgender status argument may no longer be necessary, however, in light of the Supreme Court’s recent decision in Bostock v. Clayton County , 116 which held that discrimination against transgender people is sex discrimination under Title VII. 117 Justice Gorsuch’s majority opinion applied a but-for causation standard to find that “discrimination based on . . . transgender status necessarily entails discrimination based on sex.” 118 Although Bostock ’s holding formally reached only Title VII, Justice Alito’s dissent and several courts of appeals recognized that its analysis applies just as clearly to equal protection claims. 119 Just as an employer discriminates “because of sex” when it “intentionally penalizes a person [assigned] male at birth for traits or actions that it tolerates in an employee [assigned] female at birth,” 120 bans on gender-affirming care for minors discriminate because of sex when they deny minors assigned one sex at birth access to certain medical procedures for gender-affirming purposes, but allow those same procedures to be performed for minors assigned the other sex at birth for non-gender-affirming purposes. 121

(b) Government Interest. — To survive heightened scrutiny, the government’s interest must at least be “important” and the law must be “substantially related” to the advancement of the interest. 122 Gender-affirming care bans fail this means-ends inquiry along both dimensions. First, the alleged purpose of the bans — to protect children from receiving gender-affirming healthcare — is fundamentally inconsistent with the empirical evidence and the lived experiences of many trans youth showing the efficacy and safety of these treatments, 123 and is based in faulty logic. 124 It is hard to argue that “protecting” children from medically necessary healthcare that is endorsed by nearly every professional medical association in the country 125 and validated by a near-unanimous consensus in peer-reviewed literature 126 is an interest sufficiently “legitimate” to pass rational basis review, much less one “important” enough to satisfy heightened scrutiny. 127 Second, the bans fail the “substantially related” test because they are considerably underinclusive: even as they identify gender-affirming medical interventions as “dangerous and uncontrolled human medical experiment[s],” 128 they allow the same procedures to be performed on children who have “medically verifiable disorder[s] of sex development.” 129 If the bans are actually motivated by concern over the supposed dangers of puberty blockers, HRT, and GCS, providing an exception allowing those treatments to be performed for practically any medical condition other than gender dysphoria 130 is hardly “substantially related” to abating these alleged harms.

If their purposes are taken at face value, the gender-affirming care bans cannot survive heightened scrutiny. But they also fail under rational basis review, since, as section A explained, their real purpose is preventing transgender children from expressing their transgender identity, 131 an expression of animus against transgender people that cannot be a legitimate government interest in the first place. 132 Animus can be demonstrated in a number of ways: based on inference from the structure of the law and through direct evidence that the law was motivated by prejudice. 133 As the Supreme Court held in City of Cleburne v. Cleburne Living Center, Inc ., 134 the structure of a classification can provide inferential evidence of animus when the alleged government interest does not support targeting the particular group over and above other similarly situated groups. 135 Thus, when state governments profess that bans on gender-affirming medical treatments are meant to protect children from invasive and life-changing medical procedures, but only ban procedures that are performed for the purpose of affirming a trans youth’s gender identity, the arbitrariness of the classification suggests the stated interests are pretext for animus. 136

Ultimately, however, this structural analysis is probably unneeded because there is abundant direct evidence of animus against transgender people surrounding the bans. 137 For example, during a private meeting, the Florida bill’s sponsor told a nonbinary opponent of the bill that transgender people “manufacture” their identities. 138 The author of the South Dakota legislation labeled medical transition in minors a “crime against humanity” and analogized it to medical experimentation at Auschwitz. 139 The lead sponsor of the Colorado bill admitted he was “not concerned” about the potential impact of the bill on the mental health of trans youth in the state, but was disturbed by “a progression of acceptance of young kids being sterilized.” 140 The organizations that promoted these bills also demonstrate clear animus towards transgender identity. YouTube removed the video of the October 2019 Heritage Foundation event that inspired many of the bills after determining that the Heritage panelists’ incendiary comments violated the YouTube hate speech policy. 141 And the Family Policy Alliance, which helped draft many of the bills, declares prominently on its website that it “oppose[s] . . . attempts to normalize” being transgender, “especially amongst impressionable children.” 142

2. Due Process and Parental Rights.

The gender-affirming care bans also arguably violate the Fourteenth Amendment’s due process guarantee of parents ’ rights to make decisions about the upbringing of their children. The due process right to freedom in child rearing is one of the foundational rights protected under substantive due process doctrine, dating back to the early twentieth century 143 and consistently reaffirmed since then. 144 It protects parents’ ability to make important decisions about “the care, custody, and control of their children” free from government interference, 145 based on the presumption that a parent, not the state, is in the best position to determine their child’s best interests. 146 The Supreme Court has never explicitly held that the due process right to freedom in child rearing encompasses the right to direct a child’s medical care, but has implied as much in at least one case. 147 Many other courts and commentators have presumed that parents’ common law right to supervise their children’s healthcare is constitutionally protected. 148 Gender-affirming care bans would likely violate this right. Prohibiting parents from authorizing medically necessary treatment for their children when they believe this care is in their children’s best interests is just the kind of intrusive government conduct that parental due process rights guard against.

Of course, parental rights are not absolute. The state can limit parental autonomy in medical decisionmaking in order to prevent injury to children’s health and well-being. 149 For example, many states have passed bans on conversion therapy for minors based on the nearly unanimous medical consensus that such treatment is harmful and dangerous. 150 Courts have upheld these bans against due process challenges on the ground that “the fundamental rights of parents do not include the right to choose . . . a specific medical or mental health treatment that the state has reasonably deemed harmful.” 151

The test is whether the treatment is actually harmful or reasonably believed to be harmful, which depends on the weight of scientific evidence for the legislature’s judgment. Conversion therapy bans do not violate due process because a considerable scientific consensus views conversion therapy as harmful and senseless. 152 The crucial difference in the case of gender-affirming care bans is that the weight of the scientific supermajority, 153 along with a growing canon of empirical research 154 and the lived experiences of thousands of trans youth who benefit from gender-affirming care, is against the legislatures’ judgments that gender-affirming care is harmful.

None of this is to say that challenges to gender-affirming healthcare bans on due process grounds are certain to prevail. Courts often fail to interrogate the factual underpinnings of a legislature’s judgment because their focus is more directly trained on rooting out the motivations of the legislature than on checking the lawmakers’ work in an empirical sense, 155 or because they are distracted by their moral preconceptions of an issue. 156 This failure is unfortunately commonplace in transgender rights cases, 157 though recent decisions have shown improvement in this regard. 158 There is also a risk that parental due process arguments could be turned against trans youth who seek to use state resources to obtain access to gender-affirming care against the wishes of unaccepting parents. Detailed exploration of this question is not possible here, but it is doubtful that the best-interests presumption applies if the parent’s decision not to accept their child’s transgender identity or desire to transition is motivated by prejudice, to which “the law cannot, directly or indirectly, give . . . effect.” 159

Anxiety about gender-affirming medical interventions for trans youth is understandable in many respects. Puberty blockers, HRT, and GCS are dramatic and life-changing decisions. However, a failure to intervene can be equally consequential. In other words, foregoing gender-affirming care “is not a neutral option” 160 for trans youth: it is a choice that imposes significant risks of physical, mental, social, and legal harms. Even so, this Chapter does not argue that every trans youth must transition before adulthood. Although evidence suggests this is the best option in many cases, every trans youth is different, and many transgender people live happy and healthy lives after transitioning as adults. Nor does this Chapter have the scope to opine on the ideal distribution of agency in these decisions between doctors, parents, and trans youth, beyond the observation that parents’ animus or prejudice against transgender people should not inhibit a youth’s access to care. 161 Ultimately, “protecting” trans youth requires allowing them to access medical care that permits them to live according to their own definitions of themselves, rather than the definitions ascribed to them by politicians whose goal is not protection, but suppression of children whose identities threaten their worldview. Perhaps lawmakers will one day realize this. But for now, the issue of gender-affirming healthcare for trans youth remains a heated battleground in the culture war, with the rights of thousands of children once again subject to political will.

^ Pam O’Brien, How Nicole Maines Is Paving the Way for the Next Generation of LGBTQ Youth , Shape (Aug. 15, 2019), <a href=" https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl ">https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl">https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl [ https://perma.cc/5QET-8948 ].

^ See Michelle M. Johns et al., Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017 , 68 Morbidity & Mortality Wkly. Rep . 67, 70 (2019).

^ Hereinafter “trans youth,” which this Chapter defines as transgender children and adolescents between roughly twelve and eighteen years of age.

^ This Chapter assumes basic familiarity with terms like “transgender” and “cisgender” and with the difference between assigned sex at birth and gender identity. For an introductory explanation of these concepts, see Understanding Gender , Gender Spectrum , <a href=" https://genderspectrum.org/articles/understanding-gender ">https://genderspectrum.org/articles/understanding-gender">https://genderspectrum.org/articles/understanding-gender [ https://perma.cc/U635-823E ].

^ See Jason Rafferty, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , Pediatrics , Oct. 2018, at 1, 4–5.

^ See generally, e.g ., Emily Ikuta, Note, Overcoming the Parental Veto: How Transgender Adolescents Can Access Puberty-Suppressing Hormone Treatment in the Absence of Parental Consent Under the Mature Minor Doctrine , 25 S. Cal. Interdisc. L.J. 179 (2016) (describing the problems that arise when the parent of a trans youth refuses to provide consent to gender-affirming treatment for their child, and how minors can argue for the right to consent).

^ See, e.g ., Diane Ehrensaft, Gender Nonconforming Youth: Current Perspectives , 8 Adolescent Health Med. & Therapeutics 57, 57–58 (2017). This increased research and attention has largely centered on the experiences of youth who transition from one binary gender to the other, and has neglected the experiences of nonbinary youth. Abbie E. Goldberg et al., Health Care Experiences of Transgender Binary and Nonbinary University Students , 47 Counseling Psych . 59, 86 (2019). For more on the experiences of nonbinary youth in transgender healthcare, see, for example, Gary E. Butler, Child and Adolescent Endocrinology , in Genderqueer and Non-binary Genders 171, 177–79 (Christina Richards, Walter Pierre Bouman & Meg-John Barker eds., 2017); and Goldberg et al., supra , at 86–90.

^ This Chapter uses the umbrella term “gender-affirming healthcare” to describe the range of medical services that trans youth use to bring their bodies and lived experiences into alignment with their gender identities (“transition”).

^ See Past Legislation Affecting LGBT Rights Across the Country , ACLU (Mar. 20, 2020), https://www.aclu.org/past-legislation-affecting-lgbt-rights-across-country-2020 [ https://perma.cc/KQ6T-KDR2 ] [hereinafter ACLU Legislation Tracker ]; H.B. 3515, 101st Gen. Assemb., Reg. Sess. (Ill. 2019). The Illinois bill was originally introduced in 2019, but changed sponsors in 2020. See Bill Status of HB 3515 , Ill. Gen. Assembly , https://www.ilga.gov/legislation/BillStatus.asp?DocNum=3515&GAID=15&DocTypeID=HB&SessionID=108&GA=101 [ https://perma.cc/6S5R-6SX9 ].

^ See ACLU Legislation Tracker , supra note 9; Bill Status of HB 3515 , supra note 9.

^ See H.B. 1, 2021 Leg., Reg. Sess. (Ala. 2021); S.B. 224, 122d Gen. Assemb., 1st Reg. Sess. (Ind. 2021); H. File 193, 89th Gen. Assemb., Reg. Sess. (Iowa 2021); H.B. 33, 101st Gen. Assemb., 1st Reg. Sess. (Mo. 2021); H.B. 113, 67th Leg., Reg. Sess. (Mont. 2021); H.B. 68, 167th Gen. Ct., Reg. Sess. (N.H. 2021); S.B. 676, 58th Leg., 1st Reg. Sess. (Okla. 2021); H.B. 92, 64th Leg., Gen. Sess. (Utah 2021); H.B. 68, 87th Leg., Reg. Sess. (Tex. 2020). For an up-to-date list of gender-affirming care bans filed in 2021, see Legislative Tracker: Anti-transgender Medical Care Bans , Freedom for All Ams ., <a href=" https://freedomforallamericans.org/legislative-tracker/medical-care-bans ">https://freedomforallamericans.org/legislative-tracker/medical-care-bans/">https://freedomforallamericans.org/legislative-tracker/medical-care-bans [ https://perma.cc/JX3V-J3US ].

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 [151] (Eng.).

^ Because the rationales and legal errors underlying the 2021 bills were substantially the same as the 2020 bills, and because the 2021 bills were rapidly evolving and changing at the time of publication, this Chapter focuses its critique on the 2020 bills rather than the 2021 bills.

^ See, e.g ., Hallie Horowitz, Introduction to Just Evelyn, Mom, I Need to Be a Girl 4, 4 (1998), <a href=" https://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf ">http://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf">https://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf [ https://perma.cc/LD34-7MYX ] (describing “one of the first” adolescent transitions in the mid-1990s).

^ Johns et al., supra note 2, at 68. 1.6 percent said they were “not sure.” Id .

^ See Ehrensaft, supra note 7, at 57–58.

^ World Pro. Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People 5 (7th ed. 2012) [hereinafter WPATH SOC]. Importantly, dysphoria is a psychological condition that results from a difference between gender identity and assigned sex at birth; transgender identity is not itself a psychological condition or mental illness. See id . at 5–6.

^ See id . at 8.

^ Kellan E. Baker, The Future of Transgender Coverage , 376 New Eng. J. Med. 1801 , 1801 (2017); see Professional Organization Statements Supporting Transgender People in Health Care , Lambda Legal (Sept. 17, 2018), https://www.lambdalegal.org/sites/default/files/publications/downloads/resource_trans-professional-statements_09-18-2018.pdf [ https://perma.cc/5HTA-PUHR ] (collecting statements of medical necessity). “Medically necessary” — and the closely related term “medical necessity” — is a term of art used to describe “[h]ealth care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” Medically Necessary , HealthCare.gov , <a href=" https://www.healthcare.gov/glossary/medically-necessary ">https://www.healthcare.gov/glossary/medically-necessary/">https://www.healthcare.gov/glossary/medically-necessary [ https://perma.cc/Y6K7-HAKL ].

^ See WPATH SOC, supra note 17, at 1–2; Rafferty, supra note 5, at 6. Other medical associations also provide guidance to clinicians in specific areas of care such as hormone treatment. See, e.g ., Wylie C. Hembree et al., Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline , 102 J . Clinical Endocrinology & Metabology 3869, 3874 (2017).

^ See Am. Med. Ass’n House of Delegates, Resolution: 122, Subject: Removing Financial Barriers to Care for Transgender Patients 1 (2008), <a href=" https://www.imatyfa.org/assets/ama122.pdf ">http://www.imatyfa.org/assets/ama122.pdf">https://www.imatyfa.org/assets/ama122.pdf [ https://perma.cc/T6RY-7LZN ]; Edmo v. Corizon, Inc., 935 F.3d 757, 769 (9th Cir. 2019) (citing case law and medical authority recognizing the WPATH SOC as the prevailing medical standard).

^ See WPATH SOC, supra note 17, at 14, 18–19.

^ See Johanna Olson, Catherine Forbes & Marvin Belzer, Management of the Transgender Adolescent , 165 Archives Pediatric & Adolescent Med . 171, 174 (2011) (stating that the majority of gender specialists follow this affirming approach); Leigh A. Spivey & Laura Edwards-Leeper, Future Directions in Affirmative Psychological Interventions with Transgender Children and Adolescents , 48 J. Clinical Child & Adolescent Psych . 343, 347–48 (2019).

^ See Simone Mahfouda et al., Review, Puberty Suppression in Transgender Children and Adolescents , 5 Lancet Diabetes & Endocrinology 816, 817–18 (2017).

^ Id . at 816; see WPATH SOC, supra note 17, at 19.

^ See WPATH SOC, supra note 17, at 19; Mahfouda et al., supra note 24, at 817–18.

^ See Hembree et al., supra note 20, at 3884–85.

^ See WPATH SOC, supra note 17, at 33–34.

^ Id . at 48.

^ Id . at 38 tbl.1B.

^ Id . at 49.

^ Id . at 37 tbl.1A.

^ See Butler, supra note 7, at 179; Anna Martha Vaitses Fontanari et al., Gender Affirmation Is Associated with Transgender and Gender Nonbinary Youth Mental Health Improvement , 7 LGBT Health 237, 243 (2020).

^ See WPATH SOC, supra note 17, at 20; Hembree et al., supra note 20, at 3878 tbl.5. But see generally Ikuta, supra note 6 (describing a strategy for minors in the United States to obtain HRT without parental consent).

^ See WPATH SOC, supra note 17, at 21, 54–55; see also Olson, Forbes & Belzer, supra note 23, at 176.

^ See, e.g ., Clinical Policy Bulletin, Gender Affirming Surgery , Aetna (Jan. 12, 2021), <a href="https://www.aetna.com/cpb/medical/data/600_699/0615.html ">https://www.aetna.com/cpb/medical/data/600_699/0615.html [ https://perma.cc/C5ZK-VZAR ].

^ WPATH SOC, supra note 17, at 21; see also Masculinizing Chest Reconstruction (“Top Surgery”) , UCSF Transgender Care , <a href=" https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery ">https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery/">https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery [ https://perma.cc/6HM2-UV5W ].

^ See, e.g ., Trevor Project, National Survey on LGBTQ Youth Mental Health 2020 , at 3 (2020), <a href=" https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf ">https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf">https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf [ https://perma.cc/WXM5-JVG6 ]; Johanna Olson et al., Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria , 57 J. Adolescent Health 374, 375, 378 tbl.5 (2015).

^ Olson et al., supra note 38, at 379.

^ Id .; see also Johns et al., supra note 2, at 69 tbl.2 (finding that 43.9% of transgender high school students considered attempting and 34.6% attempted).

^ See, e.g ., Rosalia Costa et al., Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria , 12 J. Sexual Med . 2206, 2212 (2015); Annelou L.C. de Vries et al., Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment , Pediatrics , Oct. 2014, at 1, 6–7; Fontanari et al., supra note 33, at 243; Kristina R. Olson et al., Mental Health of Transgender Children Who Are Supported in Their Identities , Pediatrics , Mar. 2016, at 1, 5; Jack L. Turban et al., Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation , Pediatrics , Feb. 2020, at 1, 5; Anna I.R. van der Miesen et al., Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared with Cisgender General Population Peers , 66 J. Adolescent Health 699, 703 (2020).

^ See de Vries et al., supra note 41, at 7. See generally What Does the Scholarly Research Say About the Effect of Gender Transition on Transgender Well-Being? , Cornell Univ.: What We Know Project , <a href=" https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people ">https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people">https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people [ https://perma.cc/RZ6H-4JC8 ] [hereinafter What We Know Project ] (collecting over fifty studies showing improvements in quality of life for transgender people after gender-affirming care).

^ Lily Durwood, Katie A. McLaughlin & Kristina R. Olson, Mental Health and Self-Worth in Socially Transitioned Transgender Youth , 56 J. Am. Acad. Child & Adolescent Psychiatry 116, 116 (2017).

^ de Vries et al., supra note 41, at 7 (finding that transitioned youth exhibited “quality of life, satisfaction with life, and subjective happiness” scores similar to those of cisgender youth).

^ See Turban et al., supra note 41, at 5.

^ AACAP Statement Responding to Efforts to Ban Evidence-Based Care for Transgender and Gender Diverse Youth , Am. Acad. Child & Adolescent Psychiatry (Nov. 8, 2019), <a href=" https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx ">https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx">https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx [ https://perma.cc/WXH9-5AKY ] [hereinafter AACAP Statement ]; see also Endocrine Soc’y & Pediatric Endocrine Soc’y, Transgender Health Position Statement (2020), <a href=" https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf ">https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf">https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf [ https://perma.cc/JQ9S-TAQ2 ].

^ See, e.g ., Johns et al., supra note 2, at 69 tbl.2 (showing significantly higher rates of in-person and online bullying and feelings of unsafety at school compared to cisgender students); cf . Trevor Project , supra note 38, at 7 (showing high levels of violence and discrimination against transgender youth).

^ See sources cited supra notes 38–40 and accompanying text.

^ See Goldberg et al., supra note 7, at 7.

^ See Hembree et al., supra note 20, at 3880–81 (listing various “[i]rreversible and . . . undesirable sex characteristics” that develop during assigned-sex puberty, id . at 3881); Turban et al., supra note 41, at 6.

^ See Jenifer K. McGuire et al., Body Image in Transgender Young People: Findings from a Qualitative, Community Based Study , 18 Body Image 96, 103 (2016) (noting that transgender young people feel social stress when they exhibit physical characteristics associated with their assigned sexes); Developments in the Law — Sexual Orientation & Gender Identity , 127 Harv. L. Rev . 1680, 1726 (2014) (noting the “severe negative impact” of discrimination on trans students’ educational outcomes and that socially transitioned trans youth “report a healthier sense of belonging than their peers who are not able to express and embrace their transgender identities”).

^ See, e.g ., Laura Kuper , IMPACT LGBT Health & Dev. Program , Puberty Blocking Medications 8 (2014), <a href=" https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf ">https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf">https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf [ https://perma.cc/78G8-PAZW ] (“[I]t is more difficult to align the body with one’s affirmed gender once physical changes in [puberty] occur . . . .”). It should be noted, however, that the concept of “passing” as one’s identified gender may not apply to nonbinary individuals, whose gender identities may not align with a binary mode of gender presentation. Cf . Christina Richards, Psychology , in Genderqueer and Non-binary Genders , supra note 7, at 141, 147 (noting that the genders of nonbinary people may be “socially unintelligible” such that they “find themselves in the trap of either seeming to be what they aren’t and so being accepted, or seeming to be what they are and so facing opprobrium”).

^ See Margaret To et al., Visual Conformity with Affirmed Gender or “Passing”: Its Distribution and Association with Depression and Anxiety in a Cohort of Transgender People , 17 J. Sexual Med . 2084, 2088 (2020).

^ See id . at 2089; Brynn Tannehill, For Many Trans People, Not Passing Is Not an Option , Slate (June 27, 2018, 11:54 AM), <a href=" https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html ">https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html">https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html [ https://perma.cc/3EPP-6ZNS ].

^ See Costa et al., supra note 41, at 2212 (stating that use of puberty blockers results in “improvement in many aspects of . . . psychosocial functioning, such as mood improvement and school integration”); McGuire et al., supra note 51, at 105 (reporting increased confidence, self-acceptance, and social adjustment in trans youth who transition).

^ See, e.g ., Kuper , supra note 52, at 8; Ikuta, supra note 6, at 213.

^ See To et al., supra note 53, at 2089; Tannehill, supra note 54.

^ See Nat’l Ctr. for Transgender Equal., Summary of State Birth Certificate Gender Change Laws (2020), <a href=" https://transequality.org/sites/default/files/docs/resources/Summary of State Birth Certificate Laws Jan 2020.pdf"><a href="https://transequality.org/sites/default/files/docs/resources/Summary%20of%20State%20Birth%20Certificate%20Laws%20Jan%202020.pdf ">https://transequality.org/sites/default/files/docs/resources/Summary%20of%20State%20Birth%20Certificate%20Laws%20Jan%202020.pdf [ https://perma.cc/PP39-SYZ2 ]; Identity Document Laws and Policies , Movement Advancement Project (Feb. 11, 2021), <a href=" https://www.lgbtmap.org/equality-maps/identity_document_laws ">https://www.lgbtmap.org/equality-maps/identity_document_laws">https://www.lgbtmap.org/equality-maps/identity_document_laws [ https://perma.cc/E2BP-4HB7 ].

^ See Abbie E. Goldberg, Genny Beemyn & JuliAnna Z. Smith, What Is Needed, What Is Valued: Trans Students’ Perspectives on Trans-Inclusive Policies and Practices in Higher Education , 29 J. Educ. & Psych. Consultation 27, 31–32 (2019).

^ Jacob Gershman, States Weigh Measures to Stop Transgender Athletes from Competing in Women’s Sports , Wall St. J . (Jan. 7, 2020, 5:30 AM), <a href=" https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001 ">https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001">https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001 [ https://perma.cc/SX58-6ERN ]; see NCAA Off. of Inclusion, NCAA Inclusion of Transgender Student-Athletes 13 ( 2011) , <a href=" https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf ">http://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf">https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf [ https://perma.cc/RG7X-HHJ2 ]. Along with their campaigns against gender-affirming healthcare, see infra section B.1, pp. 2172–75, state legislatures have launched a parallel nationwide offensive against trans girls’ participation in women’s sports, see Gershman, supra ; see also , e.g ., Hecox v. Little, No. 20-cv-00184, 2020 WL 4760138, at *15, *39 (D. Idaho Aug. 17, 2020) (granting preliminary injunction against one such athletics ban on trans girls).

^ See, e.g ., NCAA Off. of Inclusion , supra note 60, at 13 (“A trans male (FTM) student-athlete who is not taking testosterone related to gender transition may participate on a men’s or women’s team.”).

^ Cf . David J. Handelsman, Angelica L. Hirschberg & Stephanie Bermon, Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance , 39  Endocrine Revs . 803, 823 (2018) (finding that higher testosterone explains “most, if not all, the sex differences in sporting performance”).

^ See The Biden Plan to Advance LGBTQ+ Equality in America and Around the World , Biden for President , <a href=" https://joebiden.com/lgbtq-policy ">https://joebiden.com/lgbtq-policy/">https://joebiden.com/lgbtq-policy [ https://perma.cc/8TDP-C4UD ]; Dear Colleague Letter on Transgender Students from Catherine E. Lhamon, Assistant Sec’y for C.R., U.S. Dep’t of Educ. & Vanita Gupta, Principal Deputy Assistant Att’y Gen. for C.R., U.S. Dep’t of Just. 3 (May 13, 2016), https://www2.ed.gov/about/offices/list/ocr/letters/colleague-201605-title-ix-transgender.pdf [ https://perma.cc/85P9-GFHP ].

^ Cf., e.g ., Adams ex rel . Kasper v. Sch. Bd., 318 F. Supp. 3d 1293, 1326 (M.D. Fla. 2018), aff’d , 968 F.3d 1286 (11th Cir. 2020) (crediting evidence of the plaintiff’s “social, medical, and legal transitions” in determining he had a right to use the boys’ restroom at school).

^ See Teo Armus, A Texas Man Says His 7-Year-Old Isn’t Transgender. Now His Custody Fight Has Reached the Governor’s Office ., Wash. Post (Oct. 24, 2019, 6:13 AM), <a href=" https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott ">https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott/">https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott [ https://perma.cc/WSH8-BDJF ].

^ See, e.g ., Senator Ted Cruz (@SenTedCruz), Twitter (Oct. 23, 2019, 7:01 PM), <a lang="en"" href=" https://twitter.com/sentedcruz/status/1187157024888496128 ">https://twitter.com/sentedcruz/status/1187157024888496128?lang=en">https://twitter.com/sentedcruz/status/1187157024888496128 [ https://perma.cc/X67V-3LQZ ] (accusing the mother of “child abuse”).

^ María Méndez, Could Transgender Kids’ Care Be Next “Bathroom Bill” for Texas Republicans? , Dall. Morning News (Oct. 25, 2019, 11:57 AM), <a href=" https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans ">https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans/">https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans [ https://perma.cc/7MCJ-DWYA ].

^ See About Heritage , Heritage Found ., <a href=" https://www.heritage.org/about-heritage/impact ">https://www.heritage.org/about-heritage/impact">https://www.heritage.org/about-heritage/impact [ https://perma.cc/TPW2-KYPQ ].

^ See, e.g ., Summit on Protecting Children from Sexualization , Heritage Found ., at 2:12:28 (Oct. 9, 2019), <a href=" https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization ">https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization">https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization [ https://perma.cc/DN2P-RRXZ ] [hereinafter Summit ]; see also Brianna January, Anti-LGBTQ Group Heritage Foundation Has Hosted Four Anti-trans Panels So Far in 2019 , Media Matters for Am . (Apr. 18, 2019, 9:18 AM), <a href=" https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far ">https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far">https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far [ https://perma.cc/Q7SK-D5DT ].

^ See Sydney Bauer, The New Anti-trans Culture War Hiding in Plain Sight , New Republic (Feb. 11, 2020), <a href=" https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight ">https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight">https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight [ https://perma.cc/ZC7X-JK3E ]; Chris Johnson, Advocates Prepare for Fight as Anti-trans Youth Legislation Advances in S.D ., Wash. Blade (Jan. 31, 2020, 2:22 PM), <a href=" https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d ">https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d/">https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d [ https://perma.cc/85YF-JHX3 ].

^ See Bauer, supra note 71; Summit , supra note 70. Model legislation is often a symptom of pervasive interest group influence in state legislatures. See Rob O’Dell & Nick Penzenstadler, You Elected Them to Write New Laws. They’re Letting Corporations Do It Instead ., USA Today (June 19, 2019, 5:56 PM), <a href=" https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002 ">https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002/">https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002 [ https://perma.cc/3ACT-WP3W ].

^ See sources cited supra note 9. Although a Utah Representative was considering a bill to ban HRT and GCS, he changed course and drafted a bill geared toward exploratory research into gender-affirming healthcare. See Connor Richards, Utah House Rejects Bill to Study Effects of Hormone Therapy on Transgender Minors , Daily Herald (Mar. 10, 2020), https://www.heraldextra.com/news/local/govt-and-politics/legislature/utah-house-rejects-bill-to-study-effects-of-hormone-therapy-on-transgender-minors/article_2fc144a0-9573-50fc-a6e7-60841a6d8632.html [ https://perma.cc/M4CH-44DC ]. The fifteen-state count thus does not include the Utah bill.

^ For a database containing links to the text, sponsors, and status of the 2020 bills, see ACLU Legislation Tracker , supra note 9. For the bills introduced so far in 2021, see sources cited supra note 11; Legislation Affecting LGBT Rights Across the Country , ACLU (Feb. 11, 2021), https://www.aclu.org/legislation-affecting-lgbt-rights-across-country [ https://perma.cc/RD96-UXDP ].

^ Tennessee’s bill banned all gender-affirming care for minors who have not started puberty, but allowed minors who have begun puberty to receive gender-affirming care upon the recommendation of three physicians. See H.B. 2576, 111th Gen. Assemb., Reg. Sess. § 1(b) (Tenn. 2020). In addition, Missouri’s, Oklahoma’s, and South Carolina’s bills did not contain a “medically verifiable” exception, see H.B. 1721, 100th Gen. Assemb., 2d Reg. Sess. (Mo. 2020); S.B. 1819, 57th Leg., 2d Reg. Sess. (Okla. 2020); H.B. 4716, 123d Gen. Assemb, Reg. Sess. (S.C. 2020), and Mississippi’s and South Dakota’s bills did not follow the eighteen-year cutoff, see S.B. 2490, 2020 Leg., Reg. Sess. § 3(b) (Miss. 2020) (defining minors as below age twenty-one); H.B. 1057, 95th Gen. Assemb., Reg. Sess. (S.D. 2020) (defining minors as below age sixteen).

^ See, e.g ., S. File 2213, 88th Gen. Assemb., Reg. Sess. § 1 (3) (Iowa 2020); H.B. 513, 133d Gen. Assemb., Reg. Sess. § 1, sec. 5128.03(C)(1) (Ohio 2020).

^ See H.B. 465, 65th Leg., 2d Reg. Sess. (Idaho 2020). The law would have defined gender-affirming care as “genital mutilation of a child,” which carries a maximum life sentence under the state criminal code. See id .; Idaho Code § 18-1506B(6) (2020).

^ Cf . Annamarie Forestiere, America’s War on Black Trans Women , Harv. C.R.-C.L. L. Rev. Amicus Blog (Sept. 23, 2020), <a href=" https://harvardcrcl.org/americas-war-on-black-trans-women ">https://harvardcrcl.org/americas-war-on-black-trans-women/">https://harvardcrcl.org/americas-war-on-black-trans-women [ https://perma.cc/DRD4-RHXY ] (noting that high poverty and homelessness rates among Black trans women affect their ability to travel); La’Tasha D. Mayes, Black Women Are Dying from a Lack of Access to Reproductive Health Services , TIME (Jan. 19, 2018, 11:53 AM), <a href=" https://time.com/5109797/black-women-dying-reproductive-health ">https://time.com/5109797/black-women-dying-reproductive-health/">https://time.com/5109797/black-women-dying-reproductive-health [ https://perma.cc/LY33-M8JL ] (showing how similar laws restricting reproductive healthcare access disparately affect people of color).

^ See ACLU Legislation Tracker , supra note 9.

^ See Bauer, supra note 71; Nico Lang, Alabama Moves Closer to Transgender Health Care Ban for Minors , NBC News (Mar. 10, 2020, 4:21 PM), <a href=" https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791 ">https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791">https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791 [ https://perma.cc/3KDX-HYYE ].

^ See Changes to State Legislative Session Dates in Response to the Coronavirus (COVID-19) Pandemic, 2020 , Ballotpedia (Jan. 21, 2021), https://ballotpedia.org/Changes_to_state_legislative_session_dates_in_response_to_the_coronavirus_(COVID-19)_pandemic,_2020 [ https://perma.cc/JK26-WYNM ]; ACLU Legislation Tracker , supra note 9 (showing that several bills died in committee in mid-March).

^ See Joellen Kralik, “ Bathroom Bill” Legislative Tracking , Nat’l Conf. of State Legislatures (Oct. 24, 2019), <a href=" https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx ">https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx">https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx [ https://perma.cc/5JH4-QPZA ] (listing the states).

^ See Elena Schneider, The Bathroom Bill that Ate North Carolina , Politico Mag . (Mar. 23, 2017), <a href=" https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944 ">https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944">https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944 [ https://perma.cc/5E4M-VHQC ]; see also N.C. Gen. Stat . § 143-760(b), (d) (repealed 2017).

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 (Eng.). The court ruled that puberty blockers are presumptively inappropriate for adolescents under sixteen, id . at [151], and that court authorization may be necessary for sixteen- and seventeen-year-olds, id . at [152].

^ See, e.g ., G.B. v. Lackner, 145 Cal. Rptr. 555, 556, 559 (Ct. App. 1978) (reversing state health department’s denial of insurance coverage for GCS).

^ See, e.g ., Whitman-Walker Clinic, Inc. v. U.S. Dep’t of Health & Hum. Servs., No. CV 20-1630, 2020 WL 5232076, at *1 (D.D.C. Sept. 2, 2020) (challenging the Trump Administration’s rescission of an Obama Administration policy banning discrimination against transgender people in healthcare). For an overview of other legal battles surrounding gender-affirming healthcare, see generally Judson Adams et al., Transgender Rights and Issues , 21 Geo. J. Gender & L . 479, 494–507 (2020).

^ S.B. 2490, 2020 Leg., Reg. Sess. § 2(1)(a) (Miss. 2020).

^ See, e.g ., id . § 2(2); H.B. 3515, 101st Gen. Assemb., Reg. Sess. § 10 (Ill. 2019). Indeed, many of the bills even share a version of the same title: “Vulnerable Child Protection Act.” See, e.g ., H.B. 303, 2020 Leg., Reg. Sess. § 1 (Ala. 2020); H.B. 1365, 2020 Leg., Reg. Sess. (Fla. 2020); H.B. 513, 133d Gen. Assemb., Reg. Sess. § 2 (Ohio 2020).

^ See Amy L. Stone, Gender Panics About Transgender Children in Religious Right Discourse , 15 J. LGBT Youth 1, 1–3 (2018).

^ See, e.g ., Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 613–14 (4th Cir. 2020); id . at 626 (Wynn, J., concurring); Doe ex rel . Doe v. Boyertown Area Sch. Dist., 897 F.3d 518, 526 (3d Cir. 2018); see also Note, Constitutional Privacy and the Fight Over Access to Sex-Segregated Spaces , 133 Harv. L. Rev . 1684, 1685 (2020).

^ See, e.g ., Grimm , 972 F.3d at 620; Doe , 897 F.3d at 538.

^ See Gabby Orr, The Wedge Issue That’s Dividing Trumpworld , Politico Mag . (Aug. 7, 2020, 7:08 AM), <a href=" https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323# ">https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323">https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323# [ https://perma.cc/M2H2-JTBL ] (noting that “public opinion [is] moving dramatically in favor” of transgender rights); Schneider, supra note 83 (detailing the backlash to House Bill 2 in North Carolina).

^ See, e.g ., Orr, supra note 92 (detailing a sharply divided opinion within the Trump reelection campaign concerning whether to embrace an explicitly antitransgender platform).

^ Professor Reva Siegel has termed this phenomenon “preservation-through-transformation.” Reva B. Siegel, “ The Rule of Love”: Wife Beating as Prerogative and Privacy , 105 Yale L.J . 2117, 2180 (1996); see id . at 2179 (“[T]he manner in which a legal system enforces social stratification . . . evolve[s] over time, changing shape as it is contested.”).

^ See Editorial, Lawmakers Reach New Low with Latest Transgender Bill , Argus Leader (Jan. 27, 2020, 10:14 AM), <a href=" https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002 ">https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002/">https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002 [ https://perma.cc/EHA6-QVMU ] (noting that the chief sponsor of the 2020 South Dakota gender-affirming care ban also introduced the state’s failed bathroom bill in 2016); Chase Strangio, Conservative Legislators Want Transgender Kids’ Lives as the New Battlefield in Their Culture War , NBC News (Jan. 17, 2021, 3:30 AM), <a href=" https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483 ">https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483">https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483 [ https://perma.cc/8AXG-39EJ ].

^ See Nancy J. Knauer, The Politics of Eradication and the Future of LGBT Rights , 21 Geo. J. Gender & L . 615, 655 (2020); Strangio, supra note 95.

^ See Clifford J. Rosky, Fear of the Queer Child , 61 Buff. L. Rev . 607, 638–39 (2013) (noting that paternalistic justifications for opposing LGBTQ youth are “more appealing to a wide audience and more challenging for LGBT advocates to rebut,” id . at 639).

^ See Strangio, supra note 95; see also Knauer, supra note 96, at 637 (“By focusing on the element of choice and the ability to change, anti-LGBT advocates . . . attempt to not only destabilize LGBT identities, but to eradicate them completely because they believe that being LGBT is not a choice that anyone should make.”).

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 (Eng.). Immediately after the High Court upheld a challenge to the National Health Service (NHS) gender-affirming treatment protocol for minors, framing the decision as an exercise of “the protective role of the court,” id . at [149], the defendant NHS trust announced a moratorium on new referrals for puberty blockers, see Owen Bowcott, Puberty Blockers: Under-16s “Unlikely to Be Able to Give Informed Consent ,” The Guardian (Dec. 1, 2020, 12:18 AM), <a href=" https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules ">https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules">https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules [ https://perma.cc/L4CR-4KJ7 ].

^ See supra p. 2175.

^ See Rafferty, supra note 5, at 4 (“[C]hildren who are prepubertal and assert [a trans identity] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender . . . .”); see also Anne A. Fast & Kristina R. Olson, Gender Development in Transgender Preschool Children , 89 Child Dev . 620, 631–32 (2018) (finding that “[a]cross all measures of preference, behavior, stereotyping, and identity . . . preschool-age socially transitioned transgender children never significantly differed from their [cisgender] peers,” id . at 631).

^ See Jesse Singal, When Children Say They’re Trans , The Atlantic (July/Aug. 2018), <a href=" https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749 ">https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749/">https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749 [ https://perma.cc/P7RZ-CH57 ].

^ See Julia Temple Newhook et al., A Critical Commentary on Follow-Up Studies and “Desistance” Theories About Transgender and Gender-Nonconforming Children , 19 Int’l J. Transgenderism 212, 212–13 (2018) (claiming that the studies showing “desistance” of gender dysphoria are methodologically flawed).

^ See id . at 218 (noting that “desistance” arguments concerning gender nonconforming youth “reinforce [a] limited binary perspective on gender and sexuality” and that “if we find that people do not fit our categories, then it is the categories that must change”); see also Goldberg et al., supra note 7, at 92.

^ See WPATH SOC , supra note 17, at 14, 18–19.

^ See Singal, supra note 102; see also WPATH SOC, supra note 17, at 18 (“Before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken . . . .”).

^ U.S. Const . amend . XIV , § 1.

^ See City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 439–40 (1985).

^ See, e.g ., Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 607 (4th Cir. 2020).

^ See, e.g ., Cleburne , 473 U.S. at 440–42; Grimm , 972 F.3d at 608; see also Ashutosh Bhagwat, Purpose Scrutiny in Constitutional Analysis , 85 Calif. L. Rev . 297, 303–04 (1997).

^ See, e.g ., Grimm , 972 F.3d at 607; Adams ex rel . Kasper v. Sch. Bd., 968 F.3d 1286, 1296, 1304 (11th Cir. 2020); Whitaker ex rel . Whitaker v. Kenosha Unified Sch. Dist. No. 1 Bd. of Educ., 858 F.3d 1034, 1051–52 (7th Cir. 2017).

^ See, e.g ., Grimm , 972 F.3d at 610; Karnoski v. Trump, 926 F.3d 1180, 1201 (9th Cir. 2019); see also Kevin M. Barry et al., A Bare Desire to Harm: Transgender People and the Equal Protection Clause , 57 B.C. L. Rev . 507, 551–67 (2016) (arguing that transgender status satisfies the four-factor test for whether a group should receive protected status).

^ See, e.g ., Whitaker , 858 F.3d at 1051; Glenn v. Brumby, 663 F.3d 1312, 1317 (11th Cir. 2011); Smith v. City of Salem, 378 F.3d 566, 568, 577 (6th Cir. 2004).

^ H.B. 321, 2020 Gen. Assemb., Reg. Sess. § 1(3) (Ky. 2020); see, e.g ., id . § 1(2); H.B. 303, 2020 Leg., Reg. Sess. § 4 (Ala. 2020). Even the bills that do not specifically except treatment of intersex or developmental conditions from the prohibitions imply through their language that the bans only apply to use of the prohibited services as gender-affirming medical treatment. See, e.g ., H.B. 2210, 100th Gen. Assemb., 2d Reg. Sess. § A(1) (Mo. 2020) (prohibiting medical providers from “administering any hormonal treatment or performing any surgical treatment for the purpose of gender reassignment ” (emphasis added)); see also S.B. 1819, 57th Leg., 2d Reg. Sess. § 1(C) (Okla. 2020).

^ See, e.g ., Christian Legal Soc’y Chapter of the Univ. of Cal., Hastings Coll. of the Law v. Martinez, 561 U.S. 661, 689 (2010) (“A tax on wearing yarmulkes is a tax on Jews.” (quoting Bray v. Alexandria Women’s Health Clinic, 506 U.S. 263, 270 (1993))).

^ 140 S. Ct. 1731 (2020).

^ See id . at 1754.

^ Id . at 1747.

^ See id . at 1783 (Alito, J., dissenting) (“By equating discrimination because of sexual orientation or gender identity with discrimination because of sex, the Court’s decision will be cited as a ground for subjecting all three forms of discrimination to [heightened scrutiny].”); see also, e.g ., Adams ex rel . Kasper v. Sch. Bd., 968 F.3d 1286, 1296 (11th Cir. 2020) (applying Bostock to find that a school board policy discriminating against transgender students was sex discrimination warranting heightened scrutiny).

^ Bostock , 140 S. Ct. at 1741.

^ See Flack v. Wis. Dep’t of Health Servs., 328 F. Supp. 3d 931, 948 (W.D. Wis. 2018) (observing that a Medicaid exclusion for gender-affirming healthcare was “a straightforward case of sex discrimination” because “if plaintiffs’ natally assigned sexes had matched their gender identities, their requested, medically necessary surgeries to reconstruct their genitalia or breasts would be covered”).

^ United States v. Virginia, 518 U.S. 515, 524 (1996) (citations omitted); see Bhagwat, supra note 110, at 304. While this test for “intermediate scrutiny” has been used for gender-based classifications, courts apply a more searching “strict scrutiny” test for certain other classifications. See id .

^ See supra section A.2, pp. 2167–72.

^ See supra section B.2, pp. 2175–78.

^ See sources cited supra note 19.

^ See, e.g ., What We Know Project , supra note 42 (stating that, of more than fifty studies published between 1991 and 2017, ninety-three percent “found that gender transition improves the overall well-being of transgender people,” and that there were “no studies concluding that gender transition causes overall harm”) ; see also sources cited supra notes 41–42. But see infra pp. 2184–85 (describing concerns with judicial analysis of scientific evidence).

^ See Bhagwat, supra note 110, at 303 (discussing rational basis review).

^ H.B. 303, 2020 Leg., Reg. Sess. § 2(1) (Ala. 2020).

^ Id . § 4(b). The Alabama bill defines “medically verifiable” conditions to include “external biological sex characteristics that are irresolvably ambiguous . . . , [such as] having both ovarian and testicular tissue,” and “[ab]normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action.” Id .

^ See, e.g ., Romer v. Evans, 517 U.S. 620, 634 (1996) (explaining that “a bare . . . desire to harm a politically unpopular group cannot constitute a legitimate government interest” (citation omitted)); City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 446–47 (1985); Susannah W. Pollvogt, Unconstitutional Animus , 81 Fordham L. Rev . 887, 888 (2012).

^ See Pollvogt, supra note 132, at 926–27.

^ 473 U.S. 432.

^ See id . at 447–50. In Cleburne , the Court held that a city’s denial of a special zoning permit to a group home for people with intellectual disabilities violated equal protection because it was founded on “irrational prejudice” against such people. Id . at 450. The Court inferred prejudice in part because the city imposed special permitting requirements on the group home for reasons such as density, traffic congestion, and exposure to litigation risk that applied equally to other high-density residential uses, such as nursing homes and dormitories, for which special permits were not required. See id . at 447–50.

^ Cf . Romer , 517 U.S. at 635; Cleburne , 473 U.S. at 450.

^ See Jessica A. Clarke, Explicit Bias , 113 Nw. U. L. Rev . 505, 511 (2018) (defending the probative value of explicit statements of bias as evidence of discriminatory intent); Pollvogt, supra note 132, at 927.

^ Jeff Taylor, Florida Lawmaker Told Nonbinary Candidate He’s “Manufacturing” His Identity , NewNowNext (Feb. 4, 2020), <a href=" https://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020 ">http://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020/">https://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020 [ https://perma.cc/3NTT-LSBB ].

^ Katie Shepherd, A GOP Lawmaker, the Son of an Auschwitz Survivor, Compared Doctors Treating Transgender Children to Nazis. He Regrets It ., Wash. Post (Jan. 28, 2020, 11:45 AM), <a href=" https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi ">https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi/">https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi [ https://perma.cc/7AJH-AMJX ]. To his credit, Rep. Deutsch later apologized. Id .

^ John Herrick, Anti-LGBTQ Bills Doomed to Die. Advocates Say They Still Take a Toll ., Colo. Indep . (Feb. 13, 2020), <a href=" https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth ">https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth/">https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth [ https://perma.cc/GQP4-8AJP ].

^ See Emily Jashinsky, Exclusive: Man Tried to Share His Regrets About Transgender Life. YouTube Censored It , Federalist (June 19, 2020), https://thefederalist.com/2020/06/19/exclusive-man-tried-to-share-his-regrets-about-transgender-life-youtube-censored-it [ https://perma.cc/9JEM-M7NJ ]; see also, e.g ., Summit , supra note 70, at 2:15:20 (panelist describing the pioneers of gender-affirming treatment for minors as “pedophile activist[s]”).

^ Transgenderism & Gender Dysphoria , Fam. Pol’y All . (internal quotation marks omitted), <a href=" https://familypolicyalliance.com/issues/sexuality/transgender ">https://familypolicyalliance.com/issues/sexuality/transgender/">https://familypolicyalliance.com/issues/sexuality/transgender [ https://perma.cc/77QD-7FMA ]; see Bauer, supra note 71.

^ See Pierce v. Soc’y of Sisters, 268 U.S. 510, 534–35 (1925); Meyer v. Nebraska, 262 U.S. 390, 399 (1923).

^ See, e.g ., Troxel v. Granville, 530 U.S. 57, 65–66 (2000); Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 851 (1992); Moore v. City of East Cleveland, 431 U.S. 494, 499 (1977); Stanley v. Illinois, 405 U.S. 645, 651 (1972).

^ Troxel , 530 U.S. at 65.

^ See id . at 69–70.

^ See Parham v. J.R., 442 U.S. 584, 603–04 (1979) (recognizing “parents’ authority to decide what is best for the[ir] child” in the medical context, id . at 604); see also Kanuszewski v. Mich. Dep’t of Health & Hum. Servs., 927 F.3d 396, 418–19 (6th Cir. 2019).

^ See, e.g ., Kanuszewski , 927 F.3d at 418–19; PJ ex rel . Jensen v. Wagner, 603 F.3d 1182, 1197 (10th Cir. 2010); Restatement of the Law, Children and the Law § 2.30 (Am. L. Inst ., Tentative Draft No. 1, 2018) ; Alicia Ouellette, Shaping Parental Authority over Children’s Bodies , 85 Ind. L.J . 955, 966–68 (2010).

^ See Prince v. Massachusetts, 321 U.S. 158, 166–67 (1944).

^ See, e.g ., Cal. Bus. & Prof. Code § 865.1 (West 2021); Editorial, A Nationwide Ban Is Needed for “Anti-gay Therapy ,” Sci. Am . (Jan. 1, 2020), <a href=" https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy ">https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy/">https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy [ https://perma.cc/BV37-ZYVH ].

^ Pickup v. Brown, 740 F.3d 1208, 1236 (9th Cir. 2014); see also, e.g ., Doe ex rel . Doe v. Governor of N.J., 783 F.3d 150, 156 (3d Cir. 2015) (same).

^ See Doe , 783 F.3d at 152–53; Pickup , 740 F.3d at 1231–32.

^ Compare, e.g ., Policy Statement, Conversion Therapy , Am. Acad. Child & Adolescent Psychiatry (2018), <a href=" https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx ">https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx">https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx [ https://perma.cc/LV4U-SV3P ] (confirming that conversion therapy “lack[s] scientific credibility and clinical utility”), and Editorial, supra note 150 (noting that various medical associations characterize conversion therapy as “useless and injurious”), with, e.g ., AACAP Statement , supra note 46 (stating that “AACAP strongly opposes any efforts . . . to block access” to “evidence-based [gender-affirming] care”), and Endocrine Soc’y & Pediatric Endocrine Soc’y, supra note 46, at 2 (describing gender-affirming care for minors as “effective, relatively safe when appropriately monitored, and . . . the standard of care” (parentheses omitted)).

^ See Joseph Landau, Broken Records: Reconceptualizing Rational Basis Review to Address “Alternative Facts” in the Legislative Process , 73 Vand. L. Rev . 425, 443–44 (2020) (noting that the doctrinal framework for judicial review of legislative purposes is ill-equipped to protect marginalized groups from “distorted legislative records” based on “alternative facts,” id . at 443).

^ See, e.g ., Gonzales v. Carhart, 550 U.S. 124, 179–82 (2007) (Ginsburg, J., dissenting) (describing the majority’s “bewildering,” id . at 179, rejection of the “significant medical authority,” id . at 180 (quoting Stenberg v. Carhart, 530 U.S. 914, 932 (2000)), supporting the use of a late-term abortion procedure to protect the patient’s health in some circumstances); id . at 182 (“Ultimately, the Court admits that moral concerns are at work . . . .” (quotation marks omitted)).

^ See, e.g ., Gibson v. Collier, 920 F.3d 212, 223 (5th Cir. 2019) (“There is no medical consensus that sex reassignment surgery is a necessary or even effective treatment for gender dysphoria.”).

^ See, e.g ., Edmo v. Corizon, Inc., 935 F.3d 757, 803 (9th Cir. 2019) (holding that prison officials’ denial of medically necessary gender-affirming medical care violated the Eighth Amendment).

^ Palmore v. Sidoti, 466 U.S. 429, 433 (1984).

^ WPATH SOC, supra note 17, at 21.

^ See Ikuta, supra note 6, at 227–28.

• Health Care Law
• LGBT Rights

April 12, 2021

More from this Issue

Reframing the harm: religious exemptions and third-party harm after little sisters.

Chapter Two

The Legal Infrastructure of Childbirth

Chapter Three

Conditions of Confinement, COVID-19, and the CDC

Chapter Four

State health plans must cover gender-affirming surgery, US appeals court rules

• Medium Text

Sign up here.

Reporting By Brendan Pierson in New York, Editing by Alexia Garamfalvi and Bill Berkrot

Our Standards: The Thomson Reuters Trust Principles. New Tab , opens new tab

Thomson Reuters

Brendan Pierson reports on product liability litigation and on all areas of health care law. He can be reached at [email protected].

Read Next / Editor's Picks

Industry Insight Chevron

Mike Scarcella, David Thomas

Karen Sloan

Henry Engler

Diana Novak Jones