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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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Gender Affirmation Surgeries

Featured Expert:

Fan Liang, M.D.

Surgeries are not required for gender affirmation, but many patients choose to undergo one or more surgical procedures. Talk with your doctor to discuss what surgical options may be right for you. The following is an overview of gender affirmation surgeries.

• Penile construction (phalloplasty/metoidioplasty) : This surgical procedure can include removal of the vagina (vaginectomy), reconstruction of the urethra and penile reconstruction. Surgeons may use either vaginal tissue or tissue from another part of the body to construct the penis.
• Vaginal construction (vaginoplasty) : This surgical procedure is a multistage process during which surgeons may remove the penis (penectomy) and the testes (orchiectomy), if still present, and use tissues from the penis to construct the vagina, the clitoris (clitoroplasty) and the labia (labiaplasty).
• Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.
• Facial gender surgery can include a variety of procedures to create more feminine features , like reshaping the nose; brow lift (or forehead lift); chin, cheek and jaw reshaping; Adam’s apple reduction; lip augmentation; hairline restoration; and earlobe reduction. 
• Facial gender surgery can also include a series of procedures to create more masculine features , such as forehead lengthening and augmentation; cheek augmentation;  reshaping the nose  and chin;  jaw augmentation ; and thyroid cartilage enhancement to construct an Adam’s apple.
• Hysterectomy : This surgical procedure includes the removal of the uterus and ovaries (oophorectomy). There are options for oocyte storage and fertility preservation that you may want to discuss with your doctor. 
• Some people may combine this procedure with a scrotectomy , which is surgery to remove all or part of the scrotum. For others, the skin of the scrotum can be used in vulvoplasty or vaginoplasty ― the surgical construction of a vulva or vagina.
• The procedure reduces testosterone production and may eliminate the need for continuing therapy with estrogen and androgen-suppressing medications. Your health care practitioner will discuss options such as sperm freezing before orchiectomy that can preserve your ability to become a biological parent.

Recovery After Gender Affirmation Surgeries

Recovery time from a gender affirmation surgery or procedure varies, depending on the procedure. Talk to your doctor about what you can expect.

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary , to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

• Decreased antidepressant use
• Decreased anxiety, depression, and suicidal ideation
• Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

• Both a man and a woman
• Neither a man nor a woman
• An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

• Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
• Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
• Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

• Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
• Hysterectomy (uterus removal)
• Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
• Oophorectomy (ovary removal)
• Phalloplasty (surgery to create a penis )
• Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

• Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
• Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

• Constructing a glans (head) to look more like a penis
• Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
• Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

• Breast augmentation
• Facial feminization surgery
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
• Vaginoplasty
• Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

• Acute kidney injury
• Blood transfusion
• Deep vein thrombosis, which is blood clot formation
• Pulmonary embolism, blood vessel blockage for vessels going to the lung
• Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
• Surgical site infection
• Urethral stricture or stenosis, which is when the urethra narrows
• Urinary tract infection (UTI)
• Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

American Society of Plastic Surgeons. Gender affirmation surgeries .

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-e2330348. doi:10.1001/jamanetworkopen.2023.30348

Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8 .  Int J Transgend Health . 2022;23(S1):S1-S260. doi:10.1080/26895269.2022.2100644 

Chou J, Kilmer LH, Campbell CA, DeGeorge BR, Stranix JY. Gender-affirming surgery improves mental health outcomes and decreases anti-depressant use in patients with gender dysphoria .  Plast Reconstr Surg Glob Open . 2023;11(6 Suppl):1. doi:10.1097/01.GOX.0000944280.62632.8c

Human Rights Campaign. Get the facts on gender-affirming care .

Human Rights Campaign. Transgender and non-binary people FAQ .

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877–84. doi:10.21037/tau.2016.09.04

Richards JE, Hawley RS. Chapter 8: Sex Determination: How Genes Determine a Developmental Choice . In: Richards JE, Hawley RS, eds. The Human Genome . 3rd ed. Academic Press; 2011: 273-298.

Randolph JF Jr. Gender-affirming hormone therapy for transgender females . Clin Obstet Gynecol . 2018;61(4):705-721. doi:10.1097/GRF.0000000000000396

Cocchetti C, Ristori J, Romani A, Maggi M, Fisher AD. Hormonal treatment strategies tailored to non-binary transgender individuals . J Clin Med . 2020;9(6):1609. doi:10.3390/jcm9061609

Van Boerum MS, Salibian AA, Bluebond-Langner R, Agarwal C. Chest and facial surgery for the transgender patient .  Transl Androl Urol . 2019;8(3):219-227. doi:10.21037/tau.2019.06.18

Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes . Transl Androl Urol . 2019;8(3):248–53. doi:10.21037/tau.2019.06.12

Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: surgical options and outcomes in 813 cases .  Front Endocrinol . 2021;12:760284. doi:10.3389/fendo.2021.760284

Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The surgical techniques and outcomes of secondary phalloplasty after metoidioplasty in transgender men: an international, multi-center case series .  The Journal of Sexual Medicine . 2019;16(11):1849-1859. doi:10.1016/j.jsxm.2019.07.027

Waterschoot M, Hoebeke P, Verla W, et al. Urethral complications after metoidioplasty for genital gender affirming surgery . J Sex Med . 2021;18(7):1271–9. doi:10.1016/j.jsxm.2020.06.023

Nikolavsky D, Hughes M, Zhao LC. Urologic complications after phalloplasty or metoidioplasty . Clin Plast Surg . 2018;45(3):425–35. doi:10.1016/j.cps.2018.03.013

Nota NM, den Heijer M, Gooren LJ. Evaluation and treatment of gender-dysphoric/gender incongruent adults . In: Feingold KR, Anawalt B, Boyce A, et al., eds.  Endotext . MDText.com, Inc.; 2000.

Carbonnel M, Karpel L, Cordier B, Pirtea P, Ayoubi JM. The uterus in transgender men . Fertil Steril . 2021;116(4):931–5. doi:10.1016/j.fertnstert.2021.07.005

Miller TJ, Wilson SC, Massie JP, Morrison SD, Satterwhite T. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes . JPRAS Open . 2019;21:63-74. doi:10.1016/j.jpra.2019.03.003

Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals . Clin Plast Surg . 2018;45(3):369–80. doi:10.1016/j.cps.2018.03.010

De Boulle K, Furuyama N, Heydenrych I, et al. Considerations for the use of minimally invasive aesthetic procedures for facial remodeling in transgender individuals .  Clin Cosmet Investig Dermatol . 2021;14:513-525. doi:10.2147/CCID.S304032

Asokan A, Sudheendran MK. Gender affirming body contouring and physical transformation in transgender individuals .  Indian J Plast Surg . 2022;55(2):179-187. doi:10.1055/s-0042-1749099

Sturm A, Chaiet SR. Chondrolaryngoplasty-thyroid cartilage reduction . Facial Plast Surg Clin North Am . 2019;27(2):267–72. doi:10.1016/j.fsc.2019.01.005

Chen ML, Reyblat P, Poh MM, Chi AC. Overview of surgical techniques in gender-affirming genital surgery . Transl Androl Urol . 2019;8(3):191-208. doi:10.21037/tau.2019.06.19

Wangjiraniran B, Selvaggi G, Chokrungvaranont P, Jindarak S, Khobunsongserm S, Tiewtranon P. Male-to-female vaginoplasty: Preecha's surgical technique . J Plast Surg Hand Surg . 2015;49(3):153-9. doi:10.3109/2000656X.2014.967253

Okoye E, Saikali SW. Orchiectomy . In: StatPearls [Internet] . Treasure Island (FL): StatPearls Publishing; 2022.

Salgado CJ, Yu K, Lalama MJ. Vaginal and reproductive organ preservation in trans men undergoing gender-affirming phalloplasty: technical considerations . J Surg Case Rep . 2021;2021(12):rjab553. doi:10.1093/jscr/rjab553

American Society of Plastic Surgeons. What should I expect during my recovery after facial feminization surgery?

American Society of Plastic Surgeons. What should I expect during my recovery after transmasculine bottom surgery?

de Brouwer IJ, Elaut E, Becker-Hebly I, et al. Aftercare needs following gender-affirming surgeries: findings from the ENIGI multicenter European follow-up study .  The Journal of Sexual Medicine . 2021;18(11):1921-1932. doi:10.1016/j.jsxm.2021.08.005

American Society of Plastic Surgeons. What are the risks of transfeminine bottom surgery?

American Society of Plastic Surgeons. What are the risks of transmasculine top surgery?

Khusid E, Sturgis MR, Dorafshar AH, et al. Association between mental health conditions and postoperative complications after gender-affirming surgery .  JAMA Surg . 2022;157(12):1159-1162. doi:10.1001/jamasurg.2022.3917

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Orchiectomy (Testicle Removal) Orchiectomy may be performed to remove one or both testicles in transgender individuals. The procedure reduces the need for feminizing hormone therapy as your body will produce less testosterone.

Physical Therapy Physical therapists offer personalized exercise plans to help you manage your weight when on hormone therapy, increase muscle strength and mobility, and help with body shaping. Physical therapy can also help you rehabilitate after surgery. It may be recommended to manage lymphedema after top surgery and to help with pelvic pain or discomfort.

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Gender-Affirming Voice Services Our voice therapists and laryngologists offer gender-affirming voice services, including trans-competent voice evaluations and behavioral voice intervention, to transgender and gender-diverse adults and children. In-person and virtual appointments are available. We can help you alter your vocal pitch, intonation, timbre, nonverbal communication style, and more. Our Gender-Affirming Vocal Skills Virtual Group is open to transgender and gender non-conforming adults who want to practice their modified voices in a group setting.

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• Gender-Affirming Surgery: A Comprehensive Guide

A Comprehensive Guide to Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on April 15, 2024.

Gender-affirming surgery is an umbrella term for a series of surgical procedures that help transgender, non-binary and gender non-confirming individuals alleviate their gender dysphoria and promote a sense of congruence between their physical body and gender identity. Below we outline the different types of gender-affirming surgeries that are documented in the World Professional Association for Transgender Health’s (WPATH) Standards of Care 8 (SOC8) alongside important cost, insurance, and recovery information often solicited by patients.

At the Gender Confirmation Center (GCC), we believe that medically necessary gender-affirming surgical care should be made available to patients of diverse gender identities and body types with differing BMIs . If you are interested in making an individualized surgical plan to meet your unique needs, you can schedule a virtual or in-person consultation with one of our board-certified surgeons today.

Types of Gender-Affirming Surgeries

There are several types of gender-affirming surgeries available, each designed to help patients feel more congruence between their body and their gender identity. We highly recommend that patients seek out board-certified surgeons with hospital privileges and extensive experience in gender-affirming surgical care.

Top surgery refers to procedures that modify the chest area. In our practice, top surgery usually refers to chest reconstructions or breast reductions , both involving the removal of breast tissue. Patients can also modify the nipples through a free nipple graft to adjust the size, shape and placement of their nipples or remove the nipple completely . In addition, nerve preservation techniques can also be performed to prevent the loss of heightened, erotic sensation in the nipples.

Another type of top surgery procedure is a breast augmentation . In general, implants yield better results than fat transfers when a large increase in volume is desired and existing skin is relatively tight. Patients can choose between silicone and saline breast implants, their size and placement , as well as the location of their breast implant scars .

Bottom surgeries are gender-affirming procedures performed to reconstruct external genitalia or remove internal reproductive organs. Bottom surgery can involve the construction of structures that do not currently exist on the patient’s body (like a vaginal canal, vulva or penis).

Fertility planning considerations and/or preoperative hair removal may be required for some procedures.

• Zero-depth vaginoplasty or vulvoplasty: This involves the creation of a vulva and clitoris without the creation of a vaginal canal for penetrative sex.
• Penile-preserving vaginoplasty: This involves the creation of a vulva, clitoris, and vaginal canal by reconstructing penile and scrotal tissues.
• Labiaplasty and revisions: Dr. Ley is well-renowned for her expertise in bottom surgery revisions. These procedures allow for corrections to the size, shape and/or symmetry of their labia minora, labia majora and/or clitoral hood.
• Orchiectomy : This procedure involves the removal of the testicles. Patients interested in a vaginoplasty or vulvoplasty should have their scrotal tissue preserved for the construction of the labia. An orchiectomy can take place up to 8 weeks before their vaginoplasty or vulvoplasty procedure.
• Metoidioplasty : A metoidioplasty involves releasing erectile tissue (clitoris), from restraining structures, allowing it to move into a more forward and elevated position. This is typically less complex to perform and maintains more sensation compared to a phalloplasty procedure, but results in a smaller penis. Patients can opt for a urethral lengthening procedure the ability to urinate standing up is a priority.
• Phalloplasty : This surgery involves the creation of a penis using a tissue flap from the patient’s groin, outer thigh, or forearm. This allows the possibility of creating a larger penis that enables penetrative sex and the ability to urinate while standing. The risk of not having full, erotic sensation in the new penis may differ based on the type of phalloplasty performed.
• Hysterectomy, vaginectomy, scrotoplasty and more : Prior to, simultaneously or independent from other bottom surgery procedures, patients can have their vaginal canal, uterus and/or one or both of their ovaries removed. Dr. Ley only requires a vaginectomy or removal of the vaginal canal in the case of a urethral lengthening (to allow patients to urinate standing up) to prevent urinary complications. Additionally, Dr. Ley offers the possibility of constructing a scrotum, inserting testicular implants, and other procedures to help patients feel more aligned with their genitals.

Facial Feminization Surgery and Facial Masculinization Surgery

Gender-affirming facial surgery encompasses a broad set of procedures that seek to alter different features of the face to help patients feel more congruence between their appearance and their gender. Facial feminization surgery (FFS) involves procedures that soften facial features to give the face a more conventionally feminine appearance. Facial masculinization surgery (FMS) typically creates a more angular, and conventionally masculine appearance. Patients can choose between any of the following procedures: hairline advancement, brow bone reduction, brow bone augmentation, eyebrow lift, rhinoplasty (nose reconstruction), cheek augmentation, lip augmentation, Adam’s apple reduction/augmentation, or jaw and chin contouring or augmentation.

Body Contouring Surgery

Gender-affirming body contouring can include a variety of liposuction, fat grafting, or silicone implant procedures to alter the shape and appearance of the body. It may be helpful to learn about the common effects of androgenic and estrogenic puberties on body shapes to determine their surgical goals for Body Masculinization Surgery (BMS) or Body Feminization Surgery (BFS) . Procedures can include masculinizing liposuction , feminizing liposuction , fat transfer procedures such as a Brazilian Butt Lift (BBL) , or silicone pectoral implants .

Voice Feminization Surgery

Voice modification surgery, also known as voice feminization surgery or voice masculinization surgery, alters the vocal cords and other structures in the throat to help individuals achieve a voice that aligns with their gender identity. Procedures like a Wendler glottoplasty can help raise the pitch of the voice to create a more feminine tone by removing layers of vocal cord tissue. Vocal therapy is needed before and after surgery, not just for rehabilitation purposes, but also to help adjust resonance and tone. You can learn more about gender-affirming vocal therapy and surgical treatments from trusted providers like San Francisco Voice and Swallow .

Considerations for Gender-Affirming Surgery

Undergoing gender-affirming surgery is a deeply personal decision that requires careful consideration and preparation. It’s important to consult with qualified healthcare professionals, such as mental health providers and surgeons with expertise in gender-affirming care, to ensure that the procedures align with your goals and expectations.

Eligibility and Readiness

Most healthcare providers follow the WPATH Standards of Care , which outline criteria for eligibility and readiness for gender affirming surgeries. These criteria typically include:

• Persistent and well-documented gender dysphoria
• Capacity to make a fully informed decision and consent to treatment
• Clearance from a mental health professional experienced in treating gender dysphoria

At the GCC, we use an informed-consent model that ensures adults capable of making informed decisions are eligible for surgery. That said, patients who plan on using health insurance to cover their surgery need a letter of support from their therapist which is required for the insurance approval process. You can read more about the requirements for this process here .

Please note that per the WPATH’s SOC 8 Guidelines , patients must present a support letter from a lisenced mental health professional to be eligible for bottom surgery, regardless of whether or not you are seeking insurance coverage. However, Dr. Ley does not require that patients present a support letter to undergo a bottom surgery revision procedure. Whether or not you underwent your initial bottom surgery procedure with her, the support letter eligibility requirement will be waived.

Once you have solicited a free, virtual or in-person consultation , our patient care team can assist you in acquiring any and all of the necessary documentation.

Additional Eligibility Requirements: Age, Gender and BMI

Aside from support letters from a mental health provider, several other gatekeeping or discriminatory protocols can get in the way of a patient accessing medically necessary gender-affirming care. Historically, there have been extra barriers to access for patients who are non-binary, those with higher BMIs, and those who pursue transitional care at a later age. The GCC is one of the only practices that operate on patients with BMIs above 30 , and also has specialized protocols for patients with disabilities, adolescents and seniors. For more specific information about these eligibility requirements, click here .

Costs and Insurance Coverage

The costs of gender-affirming procedures can vary depending on the unique, surgical plan you and your surgeon come up with. Many insurance companies recognize these kinds of surgeries as medically necessary, and therefore provide full or partial coverage for them. For more information on costs and insurance coverage, click here .

Preparation for Surgical Gender Affirmation

Beyond eligibility requirements, there are various other preparations patients need to address before undergoing gender-affirming surgery. These may include:

• Undergoing laser hair removal prior to certain bottom surgery procedures
• Looking into your fertility preservation options prior to certain bottom surgery procedures
• Stopping any laser hair removal on your face at least 6 weeks prior to FFS
• Requesting time off work for surgery and recovery
• Booking travel and lodging if you are coming in from out-of-town
• Completing necessary lab work and getting your medications from the pharmacy
• Refraining from smoking any substance at least 3 weeks before and after surgery
• Refraining from drinking alcohol at least 1 week before and after surgery
• Getting a care team together of friends, loved ones and/or professionals to take care of you post-op

Recovery from Gender-Affirming Surgery

Just like preparing for surgery, recovery involves both physical and emotional processes. Emotionally, it is very common for patients to experience temporary feelings of depression and even regret in the postoperative period due to pain, inflammation and changes in mobility during recovery. As healing progresses and the results of surgery become more apparent, patients who undergo gender-affirming surgeries report significantly high levels of satisfaction . For this reason, we highly encourage patients to include supportive loved ones and/or a mental health professional as a part of their surgical recovery plan.

In terms of physical recovery, most patients will be advised to follow a low-sodium diet two weeks after surgery to reduce the formation of excessive swelling. Likewise, if surgery leaves any visible incisions, patients should follow incision and scar care protocols such as moisturizing incisions, scar massages , and minimizing sun exposure for at least a year after surgery.

You can find more specific recovery guidelines in the following articles:

• Recovering from top surgery (chest reconstruction or breast reduction)
• Recovering from breast augmentation
• Recovering from facial surgery
• Recovering from liposuction
• Recovering from fat grafting (BBL)
• Recovering from vaginoplasty, vulvoplasty and/or labiaplasty
• Recovery from metoidioplasty
• Recovery from phalloplasty

Q: Is gender affirming surgery covered by insurance?

Many insurance plans cover gender affirming surgeries. However, coverage and requirements vary by plan and state. It’s essential to check with your insurance provider for specific details on coverage, pre-authorization requirements, and any exclusions or limitations. For more information, click here .

Q: What is the recovery process like for gender affirming surgeries?

The recovery process differs depending on the specific procedure(s) performed. Generally, it involves some downtime, pain management, and follow-up appointments. Your surgeon will provide detailed recovery instructions and timelines. It’s important to follow these instructions carefully to ensure proper healing and minimize the risk of complications.

Q: Are there any risks associated with gender affirming surgeries?

As with any surgical procedure, there are potential risks and complications associated with gender affirming surgeries. These can include bleeding, infection, scarring, and adverse reactions to anesthesia. Your surgeon can discuss specific risks or complications, as well as steps to minimize these and ensure the best possible outcome. For more information on how you can minimize surgical risks, click here .

Q: How long does it take to recover from a vaginoplasty?

The recovery process for a vaginoplasty can take at least 3 months, which is when patients can begin to have penetrative sex. Initial healing typically takes 4-6 weeks, during which time you may experience discomfort, swelling, bruising, and the need for dilation to maintain the vaginal depth and width. Dilation is a life-long commitment to maintain the vaginal canal opening after surgery. However, it can take 6 months to a year for swelling to resolve so that final results are visible. For more in-depth information on vaginoplasty recovery, click here .

Q: Can gender affirming surgeries be reversed?

Depending on the surgery, some procedures can be reversed. For example, implants can be removed after a breast augmentation. However, attempting to reverse the outcomes of any surgery can be complex and may not restore function pre-operatively (i.e. inability to chest feed after mastectomy). Additionally, procedures that alter reproductive organs like an orchiectomy (removal of the testicles), hysterectomy (removal of the uterus) or oophorectomy (removal of one or more ovaries) are irreversible. For this reason, we recommend that our patients look into their fertility preservation options prior to undergoing said procedures.

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Gender-Affirming Surgeries

What is gender-affirming surgery?

Gender-affirming surgeries change the look and function of your assigned sex to more closely match the gender you identify with. Having a gender-affirming surgery may be part of your journey to becoming more of your true self.

Surgical options for gender-affirmation include facial surgery, voice surgery, and top and bottom surgeries. Patients whose assigned sex and gender identity are different may experience gender dysphoria. Gender-affirming surgery is an important part of the management of patients with gender dysphoria.

Top surgery includes procedures to create or remove breasts. Feminizing bottom surgery includes procedures to remove the penis and testicles and create a new vagina, labia and clitoris. Learn more about feminizing bottom surgery .

Masculinizing bottom surgery includes procedures to remove the uterus or add a penis for intercourse and urinating or a small penis to urinate standing up. Learn more about masculinizing bottom surgery .

We follow the World Professional Association for Transgender Health’s standards when performing gender-affirming surgeries. These guidelines are set for safe, effective physical and mental health care for transgender and gender-nonconforming patients. Requirements for each procedure will vary.

Why choose Ohio State for gender-affirming surgery?

The Ohio State Wexner Medical Center is one of only a few academic health centers in the country to offer bottom gender-affirming surgery. We have a dedicated team of medical experts in every field, and through close collaboration aim to serve the LGBTQ population of Columbus and beyond.

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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

Nature Reviews Urology volume  8 ,  pages 274–282 ( 2011 ) Cite this article

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This article has been updated

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

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Change history, 26 april 2011.

In the version of this article initially published online, the statement regarding the frequency of male-to-female transsexuals was incorrect. The error has been corrected for the print, HTML and PDF versions of the article.

Meyer, W. 3rd. et al . The Harry Benjamin International Gender Dysphoria Association's standards of care for gender identity disorders, sixth version. World Professional Association for Transgender Health [online] , (2001).

Google Scholar  

Bakker, A., Van Kesteren, P., Gooren, L. & Bezemer, P. The prevalence of transsexualism in The Netherlands. Acta Psychiatr. Scand. 87 , 237–238 (1993).

Article   CAS   Google Scholar  

Selvaggi, G. et al . Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast. Reconstr. Surg. 116 , 135e–145e (2005).

Article   Google Scholar  

Benjamin, H. (ed.) The Transsexual Phenomenon (Julian Press Inc., New York, 1966).

World Professional Association for Transgender Health [online] , (2010).

Zhou, J. N., Hofman, M. A., Gooren, L. J. & Swaab, D. F. A sex difference in the human brain and its relation to transsexuality. Nature 378 , 68–70 (1995).

Kruijver, F. P. et al . Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J. Clin. Endocrinol. Metab. 85 , 2034–2041 (2000).

Swaab, D. F., Chun, W. C., Kruijver, F. P., Hofman, M. A. & Ishuina, T. A. Sexual differentiation of the human hypothalamus. Adv. Exp. Med. Biol. 511 , 75–105 (2002).

Garcia-Falgueras, A. & Swaab, D. F. A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. Brain 131 , 3115–3117 (2008).

Cohen-Kettenis, P. & Kuiper, B. Transseksualiteit en psychotherapie [Dutch]. Tijdschr. Psychoth. 3 , 153–166 (1984).

Kuiper, B. & Cohen-Kettenis, P. Sex reassignment surgery: a study of 141 Dutch transsexuals. Arch. Sex. Behav. 17 , 439–457 (1988).

Kanhai, R. C., Hage, J. J., Karim, R. B. & Mulder, J. W. Exceptional presenting conditions and outcome of augmentation mammoplasty in male-to female transsexuals. Ann. Plast. Surg. 43 , 476–483 (1999).

Kanagalingm, J. et al . Cricothyroid approximation and subluxation in 21 male-to-female transsexuals. Laryngoscope 115 , 611–618 (2005).

Bouman, M. Laparoscopic assisted colovaginoplasty. Presented at the 2009 biennial World Professional Association for Transgender Health meeting, Oslo.

Rubin, S. O. Sex-reassignment surgery male-to-female. Review, own results and report of a new technique using the glans penis as a pseudoclitoris. Scand. J. Urol. Nephrol. Suppl. 154 , 1–28 (1993).

CAS   PubMed   Google Scholar  

Fang, R. H., Chen, C. F. & Ma, S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast. Reconstr. Surg. 89 , 679–682 (1992).

Selvaggi, G. et al . Genital sensitivity in sex reassignment surgery. Ann. Plast. Surg. 58 , 427–433 (2007).

Watanayusakul, S. SRS procedures. The Suporn Clinic [online] , (2010).

Melzer, T. Managing complications of male to female surgery. Presented at the 2007 World Professional Association for Transgender Health biennial meeting, Chicago.

Gilleard, O., Qureshi, M., Thomas, P. & Bellringer, J. Urethral bleeding following male to female gender reassignmetn surgery. Presented at the 2009 World Professional Association for Transgender Health biennial meeting, Oslo.

Beckley, I., Thomas, P. & Bellringer, J. Aetiology and management of recto-vaginal fistulas following male to female gender reassignment. Presented at 2008 EAU section of genitourinary surgeons and the EAU section of andrological urology meeting, Madrid.

Monstrey, S. et al . Chest wall contouring surgery in female-to-male (FTM) transsexuals: a new algorithm. Plast. Reconstr. Surg. 121 , 849–859 (2008).

Mueller, A. & Gooren, L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur. J. Endocrinol. 159 , 197–202 (2008).

Selvaggi, G., Elander, A. & Branemark, R. Penile epithesis: preliminary study. Plast. Reconstr. Surg. 126 , 265e–266e (2010).

Selvaggi, G. & Elander, A. Penile reconstruction/formation. Curr. Opin. Urol. 18 , 589–597 (2008).

Gilbert, D. A., Jordan, G. H., Devine, C. J. Jr & Winslow, B. H. Microsurgical forearm “cricket bat-transformer” phalloplasty. Plast. Reconstr. Surg. 90 , 711–716 (1992).

Bettocchi, C., Ralph, D. J. & Pryor, J. P. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 95 , 120–124 (2005).

Monstrey, S. et al . Penile reconstruction: is the radial forearm flap really the standard technique? Plast. Reconstr. Surg. 124 , 510–518 (2009).

Selvaggi, G. et al . Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder. Plast. Reconstr. Surg. 118 , 1171–1177 (2006).

Hoebeke, P. et al . Impact of sex reassignment surgery on lower urinary tract function. Eur. Urol. 47 , 398–402 (2005).

Agrawal, V. & Ralph, D. An audit of implanted penile prosteses in the UK. BJU Int. 98 , 393–395 (2006).

Hoebeke, P. B. et al . Erectile implants in female-to-male transsexuals: our experience in 129 patients. Eur. Urol. 57 , 334–340 (2010).

Vesely, J. et al . New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals. Ann. Plast. Surg. 58 , 544–550 (2007).

Selvaggi, G. et al . Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast. Reconstr. Surg. 123 , 1710–1718 (2009).

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Selvaggi, G., Bellringer, J. Gender reassignment surgery: an overview. Nat Rev Urol 8 , 274–282 (2011). https://doi.org/10.1038/nrurol.2011.46

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Gender-affirming surgeries rarely performed on transgender youth

July 8, 2024—A new study by researchers at Harvard T.H. Chan School of Public Health found little to no utilization of gender-affirming surgeries by transgender and gender-diverse (TGD) minors in the U.S. The study also found that cisgender minors and adults had substantially higher utilization of analogous gender-affirming surgeries than their TGD counterparts.

The study was published on June 27 in JAMA Network Open. According to the researchers, it is the first quantitative comparison of gender-affirming surgery utilization between cisgender and TGD populations.

Previous research has consistently demonstrated that gender-affirming care for TGD people can be lifesaving in mitigating negative mental health outcomes such as depression, anxiety, and suicidality. Data has been limited, however, around the rates at which TGD youth are undergoing gender-affirming care, including surgery. Despite this uncertainty, in recent years, twenty-five states have banned gender-affirming care for TGD minors. This fall, the Supreme Court will rule on whether such bans are constitutional.

In the context of this lack of data—and this contentious political climate—the researchers used the most recently available data from a 2019 nationally representative pool of medical insurance claims to identify individuals who received a gender-affirming surgery with a concurrent TGD-related diagnosis. Cases where patients had any other medical indications for surgery outside of gender-affirmation, such as breast cancer, were excluded from the analysis. The researchers also compared the relative use of breast reductions by cisgender men and TGD people. Breast reduction surgery was chosen as a point of comparison given that it is the only gender-affirming surgery that is commonly covered by insurance for minors and adults.

The study found no gender-affirming surgeries performed on TGD youth ages 12 and younger in 2019. This was expected, the researchers said, as current international guidelines do not suggest any medical or surgical intervention for TGD individuals prior to puberty. For teens ages 15 to 17 and adults ages 18 and older, the rate of undergoing gender-affirming surgery with a TGD-related diagnosis was 2.1 per 100,000 and 5.3 per 100,000, respectively. A majority of these surgeries were chest surgeries. When considering use of gender-affirming breast reductions among cisgender males and TGD people, the study found that cisgender males accounted for the vast majority of breast reductions, with 80% of surgeries among adults performed on cisgender men and 97% of surgeries among minors performed on cisgender male teens.

“We found that gender-affirming surgeries are rarely performed for transgender minors, suggesting that U.S. surgeons are appropriately following international guidelines around assessment and care,” said co-author Elizabeth Boskey , instructor in the Department of Social and Behavioral Sciences .

Lead author Dannie Dai, research data analyst in the Department of Health Policy and Management , added, “Our findings suggest that legislation blocking gender-affirming care among TGD youth is not about protecting children, but is rooted in bias and stigma against TGD identities and seeks to address a perceived problem that does not actually exist.”

The authors noted limitations to the study, including its reliance on diagnostic and procedure codes in claims data to determine clinical justifications for surgery and the TGD or cisgender identity of patients. Their analyses also did not capture self-paid surgeries.

— Maya Brownstein

Photo: iStock/nito100

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Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

Bustos, Valeria P. MD * ; Bustos, Samyd S. MD † ; Mascaro, Andres MD ‡ ; Del Corral, Gabriel MD, FACS § ; Forte, Antonio J. MD, PhD, MS ¶ ; Ciudad, Pedro MD, PhD ∥ ; Kim, Esther A. MD ** ; Langstein, Howard N. MD †† ; Manrique, Oscar J. MD, FACS ††

From the * Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

† Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

‡ Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Weston, Fla.

§ Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.

¶ Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Fla.

∥ Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

** Division of Plastic and Reconstructive Surgery, University of California, San Francisco, Calif.

†† Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y.

Published online 19 March 2021

Received for publication July 27, 2020; accepted January 25, 2021.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com .

Oscar J. Manrique, MD, FACS, Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, 160 Sawgrass Drive, Suite 120, Rochester, NY 14620, E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Background: 

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

Methods: 

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

Results: 

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin’s regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions: 

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

The authors of the March 2021 Gender Affirming Surgery Mini-series article entitled “Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence” ( Plast Reconstr Surg Glob Open . 2021;9(3):e3477), wish to make the following corrections in the tables and figures. The systematic review was re-conducted, and the meta-analysis was re-run with the updated numbers with no significant or major changes. The updated tables and figures are included below.

Plastic and Reconstructive Surgery – Global Open. 10(4):e4340, April 2022.

Introduction

Discordance or misalignment between gender identity and sex assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria. 1–3 This population has increased risk of psychiatric conditions, including depression, substance abuse disorders, self-injury, and suicide, compared with cis-gender individuals. 4 , 5 Approximately 0.6% of adults in the United States identify themselves as transgenders. 6 Despite advocacy to promote and increase awareness of the human rights of transgender and gender non-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals. 4 , 7

Gender-affirmation care plays an important role in tackling gender dysphoria. 5, 8–10 Gender-affirmation surgeries (GAS) aim to align the patients’ appearance with their gender identity and help achieve personal comfort with one-self, which will help decrease psychological distress. 5 , 10 These interventions should be addressed by a multidisciplinary team, including psychiatrists, psychologists, endocrinologists, physical therapists, and surgeons. 1 , 9 The number of GAS has consistently increased during the last years. In the United States, from 2017 to 2018, the number of GAS increased to 15.3%. 8 , 11 , 12

Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented. 5 , 13–19 However, despite this, there is a minor population that experiences regret, occasionally leading to de-transition surgeries. 20 Both regret and de-transition may add an important burden of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should be paid in identifying and recognizing the prevalence and factors associated with regret. In the present study, we hypothesized that the prevalence of regret is less than the last estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation care. Therefore, the aim of this study was to evaluate the prevalence of regret and assess associated factors in TGNB patients 13-years-old or older who underwent GAS. 20

Search Methodology

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive research of several databases from each database’s inception to May 11, 2020, for studies in both English and Spanish languages, was conducted. 21 The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced librarian, with input from the study’s principal investigator. Controlled vocabulary supplemented with keywords was used to search for studies of de-transition and regret in adult patients who underwent gender confirmation surgery. The actual strategy listing all search terms used and how they are combined is available in Supplemental Digital Content 1. ( See Supplemental Digital Content 1, which displays the search strategy. https://links.lww.com/PRSGO/B598 .)

Study Selection

Search results were exported from the database into XML format and then uploaded to Covidence. 22 The study selection was performed in a 2-stage screening process. The first step was conducted by 2 screeners (V.P.B. and S.S.B.), who reviewed titles and abstracts and selected those of relevance to the research question. Then, the same 2 screeners reviewed full text of the remaining articles and selected those eligible according to the inclusion and exclusion criteria ( Fig. 1 ). If disagreements were encountered, a third reviewer (O.J.M.) moderated a discussion, and a joint decision between the 3 reviewers was made for a final determination. Inclusion criteria were all the articles that included patients aged 13 years or more who underwent GAS and report regret or de-transition rates, and observational or interventional studies in English or Spanish language. Exclusion criteria were letter to the editors, case series with <10 patients, case reports correspondences, and animal studies.

Data Extraction/Synthesis

After selecting the articles, we assessed study characteristics. We identified year of publication, country in which the study was conducted, population size, and number of transmasculine and transfemenine patients with their respective mean age (expressed with SD, range, or interquartile range if included in the study). In addition, we extracted information of the method of data collection (interviews versus questionnaires), number of regrets following GAS, as well as the type of surgery, time of follow-up, and de-transition procedures. We classified the type of regret based on the patient’s reasons for regret if they were mentioned in the studies. We used the Pfäfflin and Kuiper and Cohen-Kettenis classifications of regret ( Table 1 ). 20 , 23

Quality Assessment

To assess the risk of bias within each study, the National Institute of Health (NIH) quality assessment tool was used. 24 This tool ranks each article as “good,” “fair,” or “poor,” and with this, we categorized each article into “low risk,” “moderate risk,” or “high risk” of bias, respectively.

Our primary outcome of interest was the prevalence of regret of transgender patients who underwent any type of GAS. Secondary outcomes of interest were discriminating the prevalence of regrets by type gender transition (transfemenine and transmasculine), and type of surgery.

Data Analysis and Synthesis

The binominal data were analyzed, and the pooled prevalence of regret was estimated using proportion meta-analysis with Stata Software/IC (version 16.1). 25 Given the heterogeneity between studies, we conducted a logistic-normal-random-effect model. The study-specific proportions with 95% exact CIs and overall pooled estimates with 95% Wald CIs with Freeman-Turkey double arcsine transformation were used. The effect size and percentage of weight were presented for each individual study. 25 , 26

To evaluate heterogeneity, I 2 statistics was used. If P < 0.05 or I 2 > 50%, significant heterogeneity was considered. A univariate meta-regression analysis was performed to assess the significance in country of origin, tools of measurement, and quality of the studies.

To assess publication bias, we used funnel plot graphic and the Egger test. If this test showed us no statistical significance ( P > 0.05), we assumed that the publication bias had a low impact on the results of our metanalysis. To assess the impact of the publication bias on our missing studies, we used the trim-and-fill method.

A sensitivity analysis was conducted to assess the influence of certain characteristics in the magnitude and precision of the overall prevalence of regret. The following characteristics were excluded: <10 participants included, and the presence of a high risk of bias.

A total of 74 articles were identified in the search, and 2 additional records were identified through other sources. After the first-step screening process, 39 articles were relevant based on the information provided in their titles and abstracts. After the second-step process, a total of 27 articles were included in the systematic review and metanalysis ( Fig. 1 ).

Based on the NIH quality assessment tool, the majority of article ranged between “poor” and “fair” categories. 24 ( See Supplemental Digital Content 2, which displays the score of each reviewed study. https://links.lww.com/PRSGO/B599 .)

Study Characteristics

In total, the included studies pooled 7928 cases of transgender individuals who underwent any type of GAS. A total of 2578 (33%) underwent transmasculine procedures, 5136 (67%) underwent transfemenine surgeries, and 1 non-binary patient underwent surgery. In Table 2 characteristics of studies are listed. Without discriminating type of surgical technique, from all transfemenine surgeries included, 772 (39.3%) were vaginoplasty, 260 (13.3%) were clitoroplasty, 107 (5.5%) were breast augmentation, 72 (3.7%) were labioplasty and vulvoplasty, and a small minority were facial feminization surgery, vocal cord surgery, thyroid cartilage reduction, and oophorectomy surgery. The rest did not specify type of surgery. In regard to transmasculine surgeries, 297 (12.4%) were mastectomies, 61 (2.6%) were phalloplasties, and 51 (2.1%) hysterectomies ( Table 3 and 4 ). Overall, follow-up time from surgery to the time of regret assessment ranged from 0.8 to 9 years ( Table 2 ).

Regrets and De-transition

Almost all studies conducted non-validated questionnaires to assess regret due to the lack of standardized questionnaires available in this topic. 15 , 19–33 Most of the questions evaluating regret used options such as, “ yes,” “sometimes,” “no” or “ all the time,” “sometimes,” “never,” or “most certainly, ” “very likely,” “maybe,” “rather not,” or “definitely not.” 14 , 18 , 19 , 23 , 27–38 Other studies used semi-structured interviews. 34 , 37 , 39–43 However, in both circumstances, some studies provided further specific information on reasons for regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44–46 Of the 7928 patients, 77 expressed regret (12 transmen, 57 transwomen, 8 not specified), understood by those who had “sometimes” or “always” felt it.

Reasons for Regret

The most prevalent reason for regret was the difficulty/dissatisfaction/acceptance in life with the new gender role. 23 , 29 , 32 , 36 , 44 Other less prevalent reasons were “failure” of surgery to achieve their surgical goals in an aesthetic level and psychological level. 29 , 32 , 36 , 47 Based on the reasons presented, we classified the types of regrets according to Pfäfflin’s types of regret and Kuiper and Cohen-Kettenis classification. According to Pfäfflin’s types, 28 patients had minor regret, and 34 patients had major regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44 , 45 Based on the Kuiper and Cohen-Kettenis regret classification, 35 patients had clear regret, 26 uncertain regret, 1 regret, and none presented with regret assumed by others. 23 In Table 5 and 6 , the reasons and classifications are shown.

Prevalence of Regret

The pooled prevalence of regret among the TGNB population after GAS was 1% (95% Confidence interval [CI] <1%–2%; I 2 = 75.1%) ( Fig. 2 ). The prevalence for transmasculine surgeries was <1% (CI <1%–<1%, I 2 = 28.8%), and for transfemenine surgeries, it was 1% (CI <1%–2%, I 2 = 75.5%) ( Fig. 3 ). The prevalence of regret after vaginoplasty was of 2% (CI <1%–4%, I 2 = 41.5%) and that after mastectomy was <1% (CI <1–<1%, I 2 = 21.8%) ( Fig. 4 ).

Meta-regression and Publication Bias

No covariates analyzed affected the pooled endpoint in this metanalysis. The Funnel Plot shows asymmetry between studies ( Fig. 5 ). The Egger test resulted in a P value of 0.0271, which suggests statistical significance for publication bias. The Trim & Fill method imputed 14 approximated studies, with limited impact of the adjusted results. The change in effect size was from 0.010 to 0.005 with no statistical significance ( Fig. 6 ).

Sensitivity Analysis

When excluding studies with sample sizes less than 10 and high-risk biased studies, the pooled prevalence was similar 1% (CI <1%–3%) compared with the pooled prevalence when those studies were included 1% (CI <1%–2%).

The prevalence of regret in the TGNB population after GAS was of 1% (CI <1%–2%). The prevalence of regret for transfemenine surgeries was 1% (CI <1%–2%), and the prevalence for transmasculine surgeries was <1% (CI <1%–<1%). Traditionally, the landmark reference of regret prevalence after GAS has been based on the study by Pfäfflin in 1993, who reported a regret rate of 1%–1.5%. In this study, the author estimated the regret prevalence by analyzing two sources: studies from the previous 30 years in the medical literature and the author’s own clinical practice. 20 In the former, the author compiled a total of approximately 1000–1600 transfemenine, and 400–550 transmasculine. In the latter, the author included a total of 196 transfemenine, and 99 transmasculine patients. 20 In 1998, Kuiper et al followed 1100 transgender subjects that underwent GAS using social media and snowball sampling. 23 Ten experienced regret (9 transmasculine and 1 transfemenine). The overall prevalence of regret after GAS in this study was of 0.9%, and 3% for transmasculine and <0.12% for transfemenine. 23 Because these studies were conducted several years ago and were limited to specific countries, these estimations may not be generalizable to the entire TGNB population. However, a clear trend towards low prevalences of regret can be appreciated.

The causes and types of regrets reported in the studies are specified and shown in Table 5 and 6 . Overall, the most common reason for regret was psychosocial circumstances, particularly due to difficulties generated by return to society with the new gender in both social and family enviroments. 23 , 29 , 32 , 33 , 36 , 44 In fact, some patients opted to reverse their gender role to achieve social acceptance, receive better salaries, and preserve relatives and friends relationships. These findings are in line with other studies. Laden et al performed a logistic regression analysis to assess potential risk factors for regret in this population. 46 They found that the two most important risk factors predicting regret were “poor support from the family” and “belonging to the non-core group of transsexuals.” 46 In addition, a study in Italy hypothesized that the high percentage of regret was attributed to social experience when they return after the surgery. 33

Another factor associated with regret (although less prevalent) was poor surgical outcomes. 20 , 23 , 36 Loss of clitoral sensation and postoperative chronic abdominal pain were the most common reported factors associated with surgical outcomes. 14 , 36 In addition, aesthetic outcomes played an important role in regret. Two studies mentioned concerns with aesthetic outcomes. 14 , 47 Only one of them quoted a patient inconformity: “body doesn’t meet the feminine ideal.” 14 Interestingly, Lawrence et al demonstrated in their study that physical results of surgery are by far the most influential in determining satisfaction or regret after GAS than any preoperative factor. 36 Concordantly, previous studies have shown absence of regret if sensation in clitoris and vaginal is achieved and if satisfaction with vaginal width is present. 36

Other factors associated to regret were identified. Blanchard et al in 1989 noted a strong positive correlation between heterosexual preference and postoperative regret. 32 All patients in this study who experienced regret were heterosexual transmen. 32 On the contrary, Lawrence et al in 2003 did not find such correlation and attributed their findings to the increase in social tolerance in North American and Western European societies. 36 Bodlund et al found that clinically evident personality disorder was a negative prognostic factor for regret in patients undergoing GAS. 48 On the other hand, Blanchard et al did not find a correlation among patient’s education, age at surgery, and gender assigned at birth. 32

In the present review, nearly half of the patients experienced major regret (based on Pfäfflin classification), meaning that they underwent or desire de-transition surgery, that will never pass through the same process again, and/or experience increase of gender dysphoria from the new gender. One study found that 10 of 14 patients with regret underwent de-transition surgeries (8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation) for reasons of social regret, true regret or feeling non-binary. 23 On the other hand, based on the Kuiper and Cohen Kettenis’ classification, half of the patients in this review had clear regret and uncertain regret . This means that they freely expressed their regret toward the procedure, but some had role reversal to the former gender and others did not. Interestingly, Pfäfflin concluded that from a clinical standpoint, trangender patients suffered from many forms of minor regrets after GAS, all of which have a temporary course. 20 This is an important consideration meaning that the actual true regret rate will always remain uncertain, as temporarity and types of regret can bring a huge challenge for assessment.

Regret after GAS may result from the ongoing discrimination that afflicts the TGNB population, affecting their freely expression of gender identity and, consequently feeling regretful from having had surgery. 15 Poor social and group support, late-onset gender transition, poor sexual functioning, and mental health problems are factors associated with regret. 15 Hence, assessing all these potential factors preoperatively and controlling them if possible could reduce regret rates even more and increase postoperative patient satisfaction.

Regarding transfemenine surgery, vaginoplasty was the most prevalent. 14 , 19 , 23 , 30–33 , 35 , 36 , 44 , 45 Interesintgly, regret rates were higher in vaginoplasties. 14 , 36 , 44 In this study, we estimated that the overall prevalence of regret after vaginoplasty was 2% (from 11 studies reviewed). This result is slightly higher than a metanalysis of 9 studies from 2017 that reported a prevalence of 1%. 13 Moreover, vaginoplasty has shown to increase the quality of life in these patients. 13 Mastectomy was the most prevalent transmasculine surgery. Also, it showed a very low prevalence of regret after mastectomy (<1%). Olson-Kennedy et al demonstrated that chest surgery decreases chest dysphoria in both minors and young adults, which might be the major reason behind our findings. 38

In the current study, we identified a total of 7928 cases from 14 different countries. To the best of our knowledge, this is the largest attempt to compile the information on regret rates in this population. However, limitations such as significant heterogeneity among studies and among instruments used to assess regret rates, and moderate-to-high risk of bias in some studies represent a big barrier for generalization of the results of this study. The lack of validated questionnaires to evaluate regret in this population is a significant limiting factor. In addition, bias can occur because patients might restrain from expressing regrets due to fear of being judged by the interviewer. Moreover, the temporarity of the feeling of regret in some patients and the variable definition of regret may underestimate the real prevalence of “true” regret.

Based on this meta-analysis, the prevalence of regret is 1%. We believe this reflects and corroborates the increased in accuracy of patient selection criteria for GAS. Efforts should be directed toward the individualization of the patient based on their goals and identification of risk factors for regrets. Surgeons should continue to rigorously follow the current Standard of Care guidelines of the World Professional Association for Transgender Health (WATH). 49

CONCLUSIONS

Our study has shown a very low percentage of regret in TGNB population after GAS. We consider that this is a reflection on the improvements in the selection criteria for surgery. However, further studies should be conducted to assess types of regret as well as association with different types of surgical procedure.

Acknowledgments

All the authors have completed the ICMJE uniform disclosure form. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media  claims only 1% of people regret their gender-affirmation surgery.

  View this post on Instagram   A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.

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Suicide-Related Outcomes Following Gender-Affirming Treatment: A Review

Daniel jackson.

1 Psychiatry and Behavioral Sciences, Norton College of Medicine, Upstate Medical University, Syracuse, USA

Gender-affirming treatment remains a topic of controversy; of particular concern is whether gender-affirming treatment reduces suicidality. A narrative review was undertaken evaluating suicide-related outcomes following gender-affirming surgery, hormones, and/or puberty blockers. Of the 23 studies that met the inclusion criteria, the majority indicated a reduction in suicidality following gender-affirming treatment; however, the literature to date suffers from a lack of methodological rigor that increases the risk of type I error. There is a need for continued research in suicidality outcomes following gender-affirming treatment that adequately controls for the presence of psychiatric comorbidity and treatment, substance use, and other suicide risk-enhancing and reducing factors. There is also a need for future systematic reviews given the inherent limitations of a narrative review. There may be implications on the informed consent process of gender-affirming treatment given the current lack of methodological robustness of the literature reviewed.

Introduction and background

Gender-affirming treatment remains a topic of controversy, with many calling for greater access to gender-affirming treatments to foster psychological well-being for transgender, nonbinary, and intersex individuals [ 1 - 6 ]. There is accumulating literature that suggests transgender individuals suffer worse mental health outcomes than their cisgender peers; of particular concern is increased suicidality [ 4 , 7 - 13 ].

The literature to date reveals concerning trends regarding suicidality in transgender individuals. A high prevalence of suicide attempts and thoughts of suicide occur in transgender youth compared to their cisgender peers [ 11 , 12 , 14 ]. Transgender US military veterans have more than 20 times higher rates of suicide-related events than cisgender veterans [ 7 ]. The prevalence of suicidal ideation and attempts varies by sample [ 8 ], with the prevalence of suicidal ideation sometimes as high as 50-75% [ 4 , 10 , 15 ]. Rates of attempted suicide can reach peaks of 30% and above [ 4 , 14 , 15 ]. One longitudinal study of over 6,000 transgender individuals in the US indicates that the highest risk of suicide is among those under 18 years of age [ 9 ].

Transgender individuals are also at increased susceptibility for various suicide risk-enhancing factors, as a growing body of literature suggests that transgender individuals face a high burden of chronic health conditions [ 16 , 17 ], psychiatric illnesses and their comorbidities [ 18 - 20 ], substance use [ 21 ], trauma and victimization [ 20 , 22 - 24 ], and housing and employment discrimination [ 25 ].

In light of this high prevalence of suicidality and the proliferation of gender-affirming treatments, a common argument by advocates of gender-affirming treatments is that such treatments are needed to reduce suicidality [ 26 - 29 ]. This review is the first of its kind to evaluate mental health outcomes from gender-affirming treatments solely from the standpoint of suicidality, with the recognition that this evaluation of suicide-related outcomes pertains to transgender individuals as a single group; however, transgender and gender-diverse individuals comprise a heterogeneous population that may experience varying degrees of health outcomes and biopsychosocial stressors [ 20 ].

On October 21, 2022, the following search strategy was used in PubMed: ("Suicide"[Mesh] OR suicid*[tiab]) AND ("Sex Reassignment Procedures"[Mesh] OR "sex change*"[tiab] OR "gender change"[tiab] OR "sex reassignment*"[tiab] OR gender reassignment*[tiab] OR "sex confirmation*"[tiab] OR "gender confirmation*"[tiab] OR "gender affirm*"[tiab] OR transitional surgery[tiab] OR "Gonadal Steroid Hormones"[Mesh] OR"Gonadotropin-Releasing Hormone"[Mesh] OR Hormon*[tiab]) AND ("Transgender Persons"[Majr] OR "Gender Dysphoria"[Majr] OR "Gender Identity"[Majr] OR transgender[tiab] OR "gender dysphoria"[tiab] OR "gender identity"[tiab]) AND (following[tiab] OR after[tiab] OR outcome[tiab]).

The search terms resulted in 49 articles, of which the title and abstract were screened for inclusion. Included studies were required to be quantitative, peer-reviewed, published in English, and had an outcome measure of suicidal ideation and/or attempt after gender-affirming surgical procedures (hysterectomy, oophorectomy, mastectomy, phalloplasty, scrotoplasty, and breast, penile, or scrotal prosthesis), hormone treatment (including puberty-blocking treatment), and any combination thereof.

Out of screening the titles and abstracts of these 49 results for relevance, 19 were evaluated via full-text review for inclusion, of which 15 met the inclusion criteria. Based on references contained in the papers initially reviewed, the full text of an additional 11 papers was screened, with eight meeting the inclusion criteria (Figure ​ (Figure1). 1 ). The papers that met the inclusion criteria are grouped according to the type of gender-affirming treatment. Most studies that include surgery had patients on cross-sex hormones, but they used surgery as the designation of categorizing outcomes before and after an intervention (Table ​ (Table1 1 ).

MtF: male-to-female; FtM: female-to-male.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

From: Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021, 372:n71. doi: 10.1136/bmj.n71 [ 30 ].

Combination or Not Specified

Hughto et al. (2020) utilized a cross-sectional, online survey of 288 US-based transgender adults via the Transgender Stress and Health Study. Bivariate and multivariable mixed-effect logistic regression analyses were used.

Participants were asked if they ever had a history of suicide attempt(s) or thoughts of suicide as a dichotomous variable before gender-affirming treatment. Prior to initiating unspecified gender-affirming treatment(s), 73.3% of the sample reported a history of suicidal ideation; this percentage dropped to 43.4% following the initiation of gender-affirming treatment. Prior to treatment initiation, 35.8% of the sample reported a history of suicide attempt(s), and 9.4% reported a history of suicide attempt(s) after initiation of gender-affirming treatment [ 39 ].

Adjusted multivariate analyses revealed greater odds of suicidal ideation (adjusted odds ratio (aOR), 3.86; 95% CI, 2.67-5.57; p < 0.001) and suicide attempt(s) (aOR, 5.52; 95% CI, 3.45-8.84; p < 0.001) before gender-affirming treatment compared to after [ 39 ]. Odds were adjusted for age, education, and gender-related discrimination. Potential interactions of psychiatric diagnostic history, psychiatric treatment after gender-affirming treatment, substance use, or time elapsed since gender-affirming treatment initiation were not evaluated.

Bränström and Pachankis (2020) conducted a total population study using the Swedish Total Population Register to evaluate the likelihood of mental health treatment following the initiation of hormone treatment or since the last surgical treatment. Hospitalization after a suicide attempt was the measure of suicidality implemented via the International Classification of Diseases, Tenth Revision (ICD-10) codes for intentional self-harm as a primary or secondary diagnosis. The population data from 2015 were utilized to avoid confounding by societal trends over time. As the primary outcome was the likelihood of mental health treatment as a function of time since the initiation of hormone treatment or since the last surgical treatment, the likelihood of mental health treatment that compared before and after gender-affirming treatment was not assessed.

Compared to the general population, transgender individuals had an increased odds of being hospitalized after a suicide attempt (aOR, 6.79; 95% CI, 4.45-10.35); however, a statistically significant relationship was not found for the odds of hospitalization after a suicide attempt after adjusting for the amount of time following the initiation of hormone treatment (aOR, 1.12; 95% CI, 0.97-1.30) or since the last surgical treatment (aOR, 0.87; 95% CI, 0.61-1.24) [ 32 ]. The odds ratios were adjusted for legal gender, age, country of birth, education, urbanicity, and household income. The odds ratios were not adjusted for any potential confounding by psychiatric diagnosis, psychiatric treatment besides inpatient hospitalization for a suicide attempt, or substance abuse.

In a subsequently published erratum, the authors noted no statistically significant difference in odds of hospitalization following a suicide attempt between transgender individuals matched by age, legal gender, education, and country of birth who had and who had not received any gender-affirming hormone or surgical treatment. The authors also reported that there was an absence of information that could be gathered on transgender individuals who died by suicide before 2015 [ 52 ].

Heylens et al. (2014) compared data from 57 Belgian transgender individuals before and after gender-affirming hormone treatment and surgery. Follow-up data were collected three to six months following the initiation of gender-affirming hormones and one to 12 months following gender-affirming surgery. Data on the history of suicide attempt(s) and thoughts of suicide via a biographic questionnaire were collected for 54 patients before treatment and 42 patients provided data after treatment. The presence of a history of suicide attempt(s) did not reach statistical significance between data collection periods (p-values not provided). One patient died by suicide [ 37 ]. There was no accounting for any potential effect of psychiatric diagnostic differences, concurrent psychiatric treatment, substance use, or other suicide risk-reducing or enhancing factors.

Glynn et al. (2016) conducted a secondary analysis of data gathered from a sample of transgender women who engaged in sex work in California. A structured questionnaire was completed by 573 transgender women. Suicidality was measured by “a single dichotomous (yes/no) item (‘Have you ever thought about committing suicide?’).” Over half of the participants (56%) reported a history of ever experiencing suicidal ideation. Bivariate analyses revealed “no significant group differences among… surgery status or hormone use regarding endorsing suicidal ideation or not” [ 36 ].

A history of ever experiencing suicidal ideation was associated with “significantly lower levels of psychological and familial social affirmation than those who did not report lifetime suicidal ideation” via independent sample t-tests. Despite the statistically significant results, no correction for multiple testing was done for suicide-related outcomes following gender-affirming treatment (Tukey’s tests were done for pairwise comparisons between racial groups), and effect sizes were not provided; however, they are likely small: receiving “psychological affirmation gender comfort” was associated with 0.5% fewer respondents experiencing suicidal ideation. Receiving “familial social affirmation satisfaction with family support” was associated with 0.11% fewer respondents experiencing suicidal ideation. Of the respondents, 2.89% were more likely to have a history of ever having suicidal ideation if they were of older age. Chi-square analysis demonstrated that white transgender women were more likely to have ever experienced suicidal ideation than other racial/ethnic groups.

Multivariate analyses demonstrated no statistically significant relationship between gender-affirmation treatments and a lifetime history of ever having suicidal ideation. Adjusted odds ratios showed a weak effect size with older age increasing the odds of ever having suicidal ideation. Adjusted odds ratios showed lower odds of ever having suicidal ideation among Latinas and Asian/Pacific Islanders, with Asian/Pacific Islanders having a larger effect size. There was no accounting of any potential confounding relationship of the results with psychiatric diagnostic history, concurrent treatment, substance use, or other suicide risk-reducing or enhancing factors besides age, ethnicity, or HIV status. The reporting of ever experiencing suicidal ideation as a dichotomous variable precluded any analysis of any relationship between the number of suicide attempts or frequency of suicidal ideation before and after any gender-affirming treatment.

Rood et al. (2015) utilized questionnaires from 350 transgender individuals in Virginia to evaluate the potential relationships between discrimination and transition status on suicide risk. Transition status according to the type and extent of treatment was not specified. Suicidality was measured by the question, ‘‘Have you ever thought about killing yourself?’’ as a dichotomous item. Regression analyses were adjusted for demographic variables; psychiatric diagnostic history was not ascertained by the questionnaire and thus was not controlled for [ 44 ].

Out of 350 individuals, 64.9% reported a history of ever experiencing suicidal ideation. Adjusted odds ratios revealed higher odds of a history of ever experiencing suicidal ideation in those who planned to pursue transition compared to those with no plan to receive treatment for transitioning (aOR, 2.85; p < 0.01). Those who lived full-time in their gender/had a full social transition had greater odds of ever experiencing thoughts of suicide compared to those with no plan to receive treatment for transitioning (aOR, 2.68; p < 0.01). Individuals who identified as female-to-male (FTM) had greater odds of ever experiencing thoughts of suicide compared to those who identified as male-to-female (MTF) (aOR, 2.48; p < 0.01). Compared to those who never experienced gender-related discrimination and had no plan to receive treatment for transitioning, those who experienced gender-related discrimination and either planned to receive gender-affirming treatment or were already living full-time as their identified gender had an increased odds of ever experiencing thoughts of suicide (aOR, 1.17; p < 0.05).

The authors interpreted these results by heavily relying on Meyer’s minority stress model [ 53 ]. When discussing the limitations of the study, there was no mention of a lack of controlling for potential confounding variables of psychiatric diagnostic history, concurrent psychiatric treatment, substance use, or time elapsed since gender-affirming treatment. Furthermore, there was no discussion of the potential limitations on the validity and generalizability of the findings based on the statistical considerations: the adjusted odds ratio for the interaction of discrimination on suicide is of low magnitude (1.17) and vulnerable to the risk of type I error given the lack of controlling for confounding variables. Likewise, the adjusted odds ratios of increased risk of thoughts of suicide for those who lived full-time in their gender (2.68) and those who planned to pursue gender-affirming treatment (2.85) compared to those with no plan to pursue gender-affirming treatment, while of a moderate magnitude, are vulnerable to either type I error or a decreased magnitude given the lack of adequate controlling for confounding variables.

Wilson et al. (2015) conducted a secondary analysis on 314 surveyed transwomen in San Francisco to compare the odds of various health outcomes according to the type of gender-affirming treatment. All but 22 of these individuals had gender-affirming treatment consisting of hormones, genital surgery, breast augmentation, or any combination thereof. Suicidality was measured as a dichotomous variable by asking the respondents if they had ever experienced thoughts of suicide [ 51 ].

Compared to those in the sample with no history of gender-affirming treatment, receiving treatment with hormones (OR = 0.2, 95% CI (0.1, 0.5)) or breast augmentation surgery (OR = 0.3, 95% CI (0.1, 0.6)) were associated with lower odds of ever having thoughts of suicide or attempting suicide. Individuals who received genital surgery did not have a statistically significant difference from those who did not receive gender-affirming treatment. The results were adjusted for age and race/ethnicity. There was no correction for any potential relationship with psychiatric diagnostic history, psychiatric treatment, substance use, or time elapsed since gender-affirming treatment, increasing the likelihood that the statistically significant results were vulnerable to a high risk of type I error.

Tucker et al. (2018) conducted a cross-sectional survey of 206 transgender veterans to compare outcomes among those who received a combination of gender-affirming hormones and surgery on both chest and genitals, hormone treatment only, hormone treatment and surgery on either chest or genitals but not both, and those with a history of no gender-affirming treatment. Participants were asked to rate the frequency of suicidal ideation from one (never) to five (very often or five or more times) within the past year. Respondents were also given question nine of the Patient Health Questionnaire-9 (PHQ-9) to assess suicidal thoughts over the previous two weeks at the time of the survey [ 47 ].

Mean scores were adjusted for age, gender, race, ethnicity, and annual household income. Analysis of covariance revealed statistically significant results with large effect sizes in lower past-year suicidal ideation for those receiving both genital and chest surgeries vs. those either receiving one surgery type only or gender-affirming hormones only (η2 = 0.051). This pattern of results continued when analyzing suicidal ideation within the past two weeks, with the addition of there being lower scores of suicidal ideation that were statistically significant and with large effect size (η2 = 0.052) for those with both genital and chest surgeries vs. no history of gender-affirming treatment.

An indirect-effects analysis was done to determine if the percentage of variance in suicidal ideation over the past two weeks between groups was due to the amount of depression over the past two weeks while controlling for covariates. An indirect effect was found for those receiving both chest and genitalia gender-affirming surgery vs. those who received no gender-affirming treatment; depression scores predicted 52.3% of the variance in suicidal ideation over the past two weeks. Similar indirect effects were found when comparing receiving surgery in one area alone or receiving gender-affirming hormones alone vs. receiving both chest and genitalia gender-affirming surgery. Psychiatric treatment, substance use, or other risk-reducing or enhancing factors for suicide besides age, gender, race, and income were not considered potential confounders.

Chaovanalikit et al. (2022) conducted a prospective cohort study in which 37 transgender women in Thailand were assessed for quality of life and mental health outcomes before and after gender-affirming surgery. Suicidality was measured utilizing the Hamilton Depression Rating Scale (HAM-D). There were statistically significant improvements in quality of life, depression, and self-esteem. There was no correction for multiple testing, measures of effect size, or control for potential confounders such as psychiatric diagnosis, history of psychiatric treatment, substance use, or demographic variables. None of these patients reported suicidal ideation or attempts after treatment [ 33 ].

McNichols et al. (2020) conducted a survey of 246 transgender men who underwent any form of masculinizing/gender-affirming surgery at Johns Hopkins. Suicidality was assessed in the survey via the questions, “Do you have a history of any of the following? (check all that apply)” and “If you had any of the following prior to surgery, which of these have improved? (check all that apply)” with “Suicide Attempt” as an answer choice. A history of suicide attempt(s) was reported by 27% of respondents, and 14% of respondents reported an improvement, with p < 0.003. While the survey questions explicitly refer to “Suicide Attempt” as an indication of suicidality, the authors refer to improvements in “suicidal ideation” in the results section [ 41 ]. There was no indication of any measurement of the number of suicide attempts before and after masculinization procedures that were more specific than whether they “improved.” There was no accounting for diagnostic history that was clinically determined and verified beyond self-report, current or past psychiatric treatment, substance use, or any interaction of time elapsed since the masculinization procedure as potential confounders. There were no measures of effect size or correction of p-values for multiple testing.

Dhejne et al. (2011) conducted a population-based matched cohort study of 324 Swedish transgender individuals who underwent gender-affirming surgery with controls matched for age, biological sex, and who were residing in Sweden during the time the case person underwent treatment. Immigrant status and history of inpatient psychiatric treatment were more common among transgender individuals than controls, so these were covariates in the calculation of hazard ratios. The two-sided significance value was set at 0.05, with no correction for multiple testing. The adjusted hazard ratio (aHR) of history of suicide attempt(s) among transgender individuals who underwent gender-affirming surgery was 4.9 (95% CI, 2.9-8.5) compared to matched controls across the entire time frame of the cohort (1973-2003). The odds of death by suicide were higher among transgender individuals who underwent gender-affirming surgery (aHR, 19.1; 95% CI, 5.8-62.9). The aHR was 7.9 (95% CI, 4.1-15.3) for the date range of 1973-1988. The aHR did not reach statistical significance for the period of 1989-2003 (aHR, 2.0; 95% CI, 0.7-5.3) [ 35 ].

Transgender women were more at risk of suicide attempt(s) than controls of either sex (aHR, 9.3; 95% CI, 4.4-19.9 for female and aHR, 10.4; 95% CI, 4.9-22.1 for male controls). Transgender men were more at risk for suicide attempt(s) compared to male controls (aHR, 6.8; 95% CI, 2.121.6), but the comparison to female controls did not reach statistical significance. The authors state, “[t]his suggests that male-to-females are at higher risk for suicide attempts after sex reassignment, whereas female-to-males maintain a female pattern of suicide attempts after sex reassignment.”

The authors did not correct for multiple testing. While psychiatric morbidity (including substance use) was controlled for in the form of a history of inpatient treatment, different psychiatric diagnostic categories were not taken into account as potential confounders. There was no consideration of any possible interaction of time elapsed since gender-affirming surgery. Most crucially, these findings refer to transgender individuals who received surgery compared to matched controls, not to these transgender individuals before their surgeries or to transgender individuals who have not undergone gender-affirming surgery.

Almazan and Keuroghlian (2021) conducted a secondary analysis of the 2015 US Transgender Survey (USTS). They evaluated 3,559 transgender individuals who underwent gender-affirming surgery of any kind, at least two years prior to responding to the survey. Suicidality was measured as dichotomous variables to whether a participant had thoughts of suicide or had a suicide attempt within the past year. Post-hoc analyses also evaluated the lifetime presence of suicidal ideation and suicide attempt(s). Undergoing gender-affirming surgery was associated with lower odds of suicidal ideation (aOR, 0.56; 95% CI, 0.50-0.64; p < 0.001) and lower odds of suicide attempt(s) (aOR, 0.65; 95% CI, 0.47-0.90; p = 0.009) within the past year compared to those who desired gender-affirming surgery but had not yet received it. The adjusted odds ratio for suicide attempt(s) did not reach statistical significance following the Bonferroni correction, which required a p < 0.002 [ 31 ].

Post-hoc analyses revealed that exposure to gender-affirming surgeries and lifetime measures of suicidal ideation or suicide attempt(s) did not reach statistical significance. Patients who received some of their desired gender-affirming surgeries had lower odds of suicidal ideation (aOR, 0.72; 95% CI, 0.63-0.81; p < 0.001) and suicide attempt(s) (aOR, 0.70; 95% CI, 0.53-0.93; p = 0.01) over the past year compared to those who desired gender-affirming surgery but had not received any, with past-year suicide attempts not reaching statistical significant following Bonferroni correction. Patients who received all of their desired surgeries had lower odds of suicidal ideation (aOR, 0.44; 95% CI, 0.38-0.51; p < 0.001) and suicide attempt(s) (aOR, 0.44; 95% CI, 0.28-0.70; p < 0.001) compared to those who desired gender-affirming surgery but had not received any. No interactions of history of mental health treatment besides gender-affirming counseling, substance use history, or time elapsed from surgery were utilized as potential confounders for initial and post-hoc analyses.

Park et al. (2022) conducted a postoperative survey of 15 patients who underwent gender-affirming surgeries from 1975 to 1989 at the University of Virginia. The postoperative data were compared to the preoperative data of 97 patients. Preoperative data revealed that 23.7% of the original sample had a history of suicidal ideation or suicide attempt(s). Of the 15 patients who responded to the postoperative survey, two reported a preoperative history of suicidal attempt(s); of those two, one reported a history of suicidal attempt(s) in the postoperative period. Eight of the 15 respondents reported a preoperative history of suicidal ideation; of these eight, one reported a history of suicidal ideation in the postoperative period [ 42 ].

There was no accounting for any possible interaction of psychiatric diagnostic history, psychiatric treatment, substance use, or other suicide risk-reducing or enhancing variables with suicidality. There was no significance testing or measure of effect size. A strength of the study was the gathering of long-term outcome data; however, contacting patients via phone to conduct the survey did not allow the authors to ascertain if any of the clinic’s patients died by suicide following the initial preoperative data collection.

De Cuypere et al. (2006) conducted a long-term follow-up study on 62 Belgians who had received gender-affirming surgery at the Gender Identity Clinic in Gent since 1986. A minimum of one year following surgery was an inclusion criterion for participation in the study. A semi-structured interview assessed suicidality via the rate of suicide attempts. Though not explicitly defined, the rate of suicide attempts was understood for the purposes of this review as the percentage of patients who had ever attempted suicide rather than the frequency of suicide attempts per person. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) axis I and II diagnoses were derived from the initial evaluation before surgery; it was unspecified if diagnostic revisions were made at long-term follow-up [ 34 ].

The suicide-attempt rate before gender-affirming surgery was 29.3%; following gender-affirming surgery, the suicide-attempt rate decreased to 5.1% (p = 0.004). The authors concluded that MTF patients attempted suicide as a means to cope with stress more frequently than FTM patients based on semi-structured interviews: “The postoperative male-to-females gave the following reasons for their suicide attempts: the end of a relationship (which they perceived as a challenge to their new gender), postoperative complications or an unease with their looks. They are more fragile when they are less credible in their new gender and when they have more pre-morbid psychiatric problems, especially personality disorders.”

Despite the claims made regarding the differences in the contributing factors for suicide attempts between MTF and FTM patients, there were no quantitative data used to support these findings. Despite the extensive gathering of various demographic and clinical data, even including data on social satisfaction before and after surgery and perceived credibility in one’s new gender, these data were not used to evaluate potential effects on differences in suicide outcomes. There was no controlling for any relationship between psychiatric diagnostic history, or the presence of psychiatric treatment on the rate of suicide before and after gender-affirming surgery was undertaken. There was no correction for multiple testing. A potential relationship of the amount of time elapsed since gender-affirming surgery on the rate of suicide was not assessed, though at least a minimum of one year had passed from surgery to the time of the survey.

Simonsen, Giraldi, et al. (2016) and Simonsen, Hald, et al. (2016) analyzed morbidity and mortality of Danish patients before and after gender-affirming surgery from 1978 to 2010. Both studies identified 104 individuals who had undergone gender-affirming surgery according to the Danish National Health Register. According to the Danish Register of Causes of Death, 10 of these 104 individuals had died following gender-affirming surgery from 1978 to 2014. Out of these 10 individuals, two had died by suicide at 19 and 26 years, respectively, following gender-affirming surgery. The studies discussed limitations from a small sample size, including insufficient statistical power [ 45 , 46 ]. Data concerning death by suicide or any other measure of suicidality before gender-affirming surgery were not compiled, preventing any before-and-after treatment comparison.

Rehman et al. (1999) conducted a follow-up study of 28 MTF individuals who had received gender-affirming surgery in New York from 1980 to 1997. Respondents had a minimum of three years post-surgery at the time of data collection. Suicidality was measured via a questionnaire by the item, “Did you have any suicidal thoughts or gestures before or after the surgery?” Two patients reported thoughts of suicide “shortly after surgery.” The authors noted a “marked decrease of suicide attempts” following surgery; however, their questionnaire did not ask about suicide attempts. It may have been that additional interviews were given [ 43 ]. Nonetheless, there was no indication that the data were collected through this method, and exact figures were not provided. One patient died by suicide in jail. A comparison via quantitative analysis of suicidality before and after gender-affirming surgery was not provided.

Hunt and Hampson (1980) conducted a follow-up study on 17 MTF individuals who underwent gender-affirming surgery. Two patients attempted suicide following surgery, within a year and six years after treatment, respectively. Both suicide attempts were in “response to the break-up of a relationship” [ 40 ]. No comparison of suicidality before and after surgery was undertaken, and the study would likely have been too underpowered to control for possible confounders of suicide risk-enhancing factors.

Hisle-Gorman et al. (2021) conducted a retrospective cohort study of 3,754 transgender and gender-diverse (TGD) youth aged eight to 21 years of age in the US military healthcare system. Mental healthcare utilization of TGD individuals was compared before and after the initiation of gender-affirming hormones or puberty blockers. Mental healthcare utilization of TGD individuals was also compared to their cisgender siblings. Suicidality was measured by the presence of a diagnosis of suicidal ideation or self-harm (non-suicidal self-injury or self-harm with suicidal intent not specified). Odds ratios and incidence rate ratios were adjusted for sex, total healthcare contacts per year, age at gender-affirming treatment initiation, use of puberty blockers vs. gender-affirming hormones, and parental rank.

TGD youth had greater odds of receiving a diagnosis for suicidal ideation or self-harm than their siblings (aOR, 7.45; 95% CI, 6.11-9.08). About a quarter of the TGD cohort were on either puberty blockers or gender-affirming hormones. Data were analyzed to compare their mental healthcare utilization from roughly seven years prior to gender-affirming treatment with one-and-a-half years following treatment initiation. The adjusted incidence rate ratio of mental healthcare visits for suicidality was higher following the initiation of gender-affirming care (adjusted incidence rate ratio, 1.74; 95% CI, 1.18-2.56) [ 38 ].

The authors noted an increased use of neuroleptics by the transgender cohort, citing concern that the result meant that lack of gender-affirming care may lead to major depressive disorder with psychotic features. The question of whether off-label use of antipsychotics for what was actually comorbid personality pathology, particularly borderline personality disorder, was never addressed, despite that TGD youth had greater odds of a personality disorder diagnosis than their cisgender siblings (aOR, 2.54; 95% CI, 1.71-3.78) and the increasing recognition of personality disorders occurring in adolescence [ 54 , 55 ]. Had the presence of personality disorders been controlled for, it is possible that the higher incidence rate ratio of mental healthcare visits for suicidality following initiation of gender-affirming treatment would not have reached statistical significance.

Tordoff et al. (2022) conducted a prospective, observational cohort study of 104 transgender and nonbinary persons aged 13-20 years at a Seattle gender clinic. Thoughts of self-harm or suicide were assessed via the PHQ-9 question nine; at baseline, 43.3% of patients reported thoughts of self-harm or suicide in the prior two weeks. Potential confounders included as covariates were temporal trends, self-reported gender, race, and ethnicity, ongoing psychiatric treatment, self-report of conflict with parents due to gender identity or expression, any substance use within the past year, and resilience.

Bivariate and multivariate analyses compared mental health outcomes from the 33.7% of participants who did not receive gender-affirming hormone treatment or puberty blockers and the 66.3% of participants who had by the end of 12-month follow-up. Bivariate analyses revealed an association of substance use with increased odds of thoughts of self-harm and suicide (aOR, 2.06; 95% CI, 1.08-3.93). The receipt of puberty blockers or gender-affirming hormones was associated with decreased odds of thoughts of suicide or self-harm (aOR, 0.47; 95% CI, 0.26-0.86). Temporal trends, self-reported gender, race, and ethnicity, ongoing psychiatric treatment, self-report of conflict with parents due to gender identity or expression, and resilience did not reach statistical significance.

Multivariate analysis demonstrated further reduced odds of thoughts of self-harm and suicide associated with the receipt of puberty blockers or gender-affirming hormones (aOR, 0.27; 95% CI, 0.11-0.65). There was an increased likelihood of thoughts of suicide or self-harm for those who did not receive puberty blockers or gender-affirming hormones at six months (aOR, 2.76; 95% CI, 1.22-6.26) but not at the other measured points in time.

This study provides fairly rigorous methods to control for confounding; in addition to the covariates accounted for in multivariate analyses, the authors employed E-value calculations to control for unmeasured confounding. In their supplementary attachment, they state that “the observed OR of 0.27 could be explained away by an unmeasured confounder that was associated with both the PB/GAH and the moderate to severe depression by a risk ratio of 3.25-fold each, above and beyond the measured confounders, but weaker confounding could not do so” [ 5 ]. The large effect size observed in this study warrants further investigation, particularly to determine how robust the effect would be after controlling for axis II diagnoses.

Zaliznyak et al. (2021) reviewed the age of first experiencing persistent gender dysphoria, age of social transition, and age of receiving gender-affirming hormone treatment in a sample of 155 transgender women and 55 transgender men in a Los Angeles clinic. All of these patients had socially transitioned and had received gender-affirming hormone treatment for at least a year. Their mental health histories were also taken. Out of the 55 transgender men, 21% had a history of at least one suicide attempt. The authors reported that out of those patients with a history of suicide attempt(s), 10% reported suicidal ideation after receiving gender-affirming hormone treatment or socially transitioning.

The authors appear to designate "Reported Current Feelings of Suicide Ideation" as whether suicidal ideation occurred after initiating gender-affirming hormone treatment or socially transitioning, thereby conflating the current reporting of suicidal ideation in a snapshot of time as the history of any suicidal ideation occurring after gender-affirming hormone treatment or socially transitioning. No patients reported suicide attempt(s) following gender-affirming hormone treatment or socially transitioning. There were no results given on the average amount of time following transitioning and suicide measures, nor were there tests of statistical significance.

The results for transgender women were reported similarly. Of 155 transgender women, 30% reported a history of suicide attempt(s); 27% of those who had a history of suicide attempt(s) reported current suicidal ideation (though later described as occurring after initiating gender-affirming hormone treatment or socially transitioning). No patients reported suicide attempt(s) following transitioning. There were no results given on the average amount of time following transitioning and suicide measures, nor were there tests of statistical significance.

The authors did not indicate whether they reviewed clinic records for any patients who died by suicide following gender-affirming hormone treatment or socially transitioning. There was no consideration of the effect of confounding diagnoses on the suicidality measures. Nevertheless, the authors conclude: “Given the high prevalence of suicidality, depression, and anxiety among transgender communities, it follows that proper measures should be taken to address the underlying condition − untreated GD [gender dysphoria]” [ 6 ].

Turban et al. (2022) examined data from over 21,000 transgender adults from the 2015 USTS. Suicidality was ascertained by inquiring whether there was any suicidal ideation with or without a plan, suicide attempt(s), or suicide attempt(s) requiring hospitalization over the year prior to the survey being taken. Individuals were asked about various demographic and other confounding variables, but any current or prior mental health treatments besides hospitalization secondary to suicide attempt(s) were not gathered and controlled for.

Those who received gender-affirming treatment during adolescence and adulthood were compared to those who desired access to these treatments but never received them. Access to these treatments in early adolescence was associated with lower odds of suicidal ideation over the past year (aOR, 0.4; 95% CI, 0.2-0.6; p < 0.001) compared to those who desired but did not attain these treatments. For late adolescence (aOR, 0.5; 95% CI, 0.4-0.7; p < 0.0001) and for adulthood (aOR, 0.8; 95% CI, 0.7-0.8; p < 0.0001), there were also lower odds of suicidality over the year preceding the survey for those who had access to gender-affirming hormones during those periods of life [ 49 ].

Post-hoc analyses revealed that access to gender-affirming hormones during adolescence rather than adulthood was associated with lower odds of suicidality (aOR, 0.7; 95% CI; 0.6-0.9; p = 0.0007); there was no difference when comparing early vs. late adolescence. As mentioned, any current or prior mental health treatments besides hospitalization secondary to suicide attempt(s) were not gathered and controlled for. The authors tried to assess a potential confounding of mental-health differences within the sample by examining those who had a lifetime history of suicidal ideation but none over the past year. There were greater odds of a lifetime history of suicidal ideation (aOR, 1.4; 95% CI, 1.3-1.5; p < 0.0001) but none in the past year for those who accessed gender-affirming hormones in adulthood. Such a comparison in adolescence did not reach statistical significance.

The authors stated that a post-hoc analysis was done by examining those who had a lifetime history of suicidal attempt(s) but none over the past year; however, the results of such an analysis were not described. It is possible that assessing the confounding of mental-health differences by comparing suicidality over the past year to a lifetime history is insufficient. There will be a higher likelihood of the presence of lifetime suicidal ideation but none for the past year not just due to mental health differences but as a function of increased age, i.e., there is a possibility that those who received gender-affirming hormones 30 years ago have a higher chance of a lifetime history of suicidality compared to those who received such treatments five years ago. Additionally, older individuals may have the benefit of potentially having a longer period of time receiving mental health treatment, which may account for no suicidality over the past year. There was no information from those who died by suicide. Finally, there was no accounting for effects due to psychiatric diagnostic history.

Puberty Blockers

Turban et al. (2020) analyzed data from the 2015 USTS to include “3,494 individuals between the ages of 18 and 36 who ever wanted pubertal suppression as part of their gender-affirming medical care” as an adolescent. The results indicated that 89 (2.5%) of this sample received puberty blockers. Univariate analyses indicated lower odds of lifetime suicidal ideation as well as suicidal ideation within the past year for those who received puberty blockers. Multivariate analyses revealed that the receipt of puberty blockers “was associated with decreased odds of lifetime suicidal ideation” (aOR, 0.3; 95% CI, 0.2-0.6). Suicidal ideation within the past year did not reach statistical significance. Lifetime suicide attempts did not reach statistical significance depending on receipt of blockers in univariate analyses and thus were not assessed with multivariate analysis [ 48 ]. The presence of mental health treatment, substance use, or psychiatric diagnostic history was neither mentioned nor controlled for.

Van der Miesen et al. (2020) compared outcomes at a gender clinic in the Netherlands between a sample from the general population: 272 transgender adolescents at referral who had not begun puberty blockers, and 178 adolescents who were currently on puberty blockers. Suicidality was measured by items asking, “I deliberately try to hurt or kill myself” and “I think about killing myself” [ 50 ].

The control group and those who were currently on puberty blockers did not have any statistically significant difference in suicidality, whereas those who were referred to the clinic but had not begun puberty blockers scored higher in suicidality than the other groups, but Cohen’s d revealed small effect sizes. There was neither mention nor control for psychiatric diagnostic history, substance use, or current psychiatric treatment.

The majority of the 23 studies reviewed claimed that various forms of gender-affirming treatment were associated with reductions in suicidality; however, the validity and robustness of their results suffered from either a lack of measures of statistical significance and effect size, correction for multiple testing, controlling for psychiatric diagnostic makeup or psychiatric treatment history, substance use, the interaction of time since receiving gender-affirming treatment, or any combination of these. The two studies that showed an increase in suicidality for those who received gender-affirming treatment suffered from many of the same problems in validity and robustness. Additionally, one of these studies did not compare suicidality outcomes before and after treatment but rather to the general population [ 35 ], and the other [ 38 ] yielded a small effect size that would likely constitute little clinical relevance; moreover, its results may not have reached statistical significance if there was adequate controlling for confounders.

Controlling for a potential effect of psychiatric diagnoses or degree of mood disturbance was undertaken by three of the studies reviewed [ 5 , 31 , 47 ]. The need to control for comorbid psychiatric diagnoses or degree of mood disturbance is highlighted by the findings of Tucker et al. (2018). Through indirect analysis, they found that depression scores predicted over half of the variance in suicidality over the past two weeks before their sample responded to the survey. The lack of accounting for psychiatric comorbidity and other dynamic suicide risk-enhancing factors may be the greatest limitation in the body of literature to date regarding suicidality outcomes following gender-affirming treatment.

The presence, type, and timing of psychiatric treatment history represent a potential confounder that was not considered by the majority of studies. Three of the reviewed studies accounted for some form of psychiatric treatment [ 5 , 35 , 38 ]. Hisle-Gorman et al. (2021) controlled for the total healthcare contacts per year (inpatient and outpatient), Dhejne et al. (2011) controlled for inpatient psychiatric treatment, and Tordoff et al. (2022) controlled for “ongoing mental health therapy.” There is accumulating evidence of the efficacy of psychiatric treatments that may lower the risk of suicide [ 56 - 58 ]. It would be beneficial for future studies to collect data for psychiatric treatment both before and after gender-affirming treatments.

Comorbid substance use has been well-documented as a concern for TGD individuals [ 19 - 21 , 59 - 61 ]. In addition to substance use being a dynamic risk factor for suicide [ 62 , 63 ], this relationship is borne out for TGD individuals as well [ 24 ]. Only two of the studies reviewed accounted for substance use [ 5 , 35 ], revealing a glaring risk of type I error in the literature, as access to gender-affirming treatment may or may not also serve as a proxy to access to other medical treatments, such as treatment for substance use.

Given that the 23 studies spanned a wide range of locations and dates conducted, it is not surprising that a uniform measure of suicidality was not employed across studies. An evaluation of the number of suicide attempts before and after gender-affirming treatment will likely be the most robust measure for suicidality rather than the presence and frequency of thoughts of suicide, particularly measures of suicidal ideation significantly limited in the expanse of time, such as the PHQ-9 question nine employed in Tordoff et al. (2022) and Tucker et al. (2018). A suicide attempt represents a more circumscribed occurrence, thus more easily and reliably quantifiable than thoughts of suicide; however, given that suicide attempts are a rarer phenomenon, the use of this outcome variable alone would yield less power and increase the risk of type II error. Nonetheless, the presence of thoughts of suicide at distinct points in time may be confounded by a diverse experience of such thoughts by individuals. For instance, individuals may be aware of a nearly ever-present sense of suicidal ideation, particularly in the presence of axis II pathology rather than a significant stressor or exacerbation of axis I pathology [ 64 ].

The potential confounding nature of utilizing the presence of suicidal ideation as the sole measure of suicidality may be reflected in the literature reviewed. For example, Almazan and Keuroghlian (2021) reported a lack of a statistically significant relationship between gender-affirming surgery and suicide attempts within the past year or the lifetime number of suicidal ideation. However, while there was not a statistically significant relationship with lifetime suicidal ideation, there was a statistically significant relationship with suicidal ideation within the past year. To have three measures of suicidality not reach statistical significance but suicidal ideation within the past year to reach statistical significance may represent multiple possibilities: suicidal ideation may be a more sensitive measure of suicidality as it is more prevalent and thus has more statistical power. Conversely, the presence of a high risk of type I error associated with recall bias and the potential inherent unreliability of suicidal ideation as a measurable construct may be detractors of its use. Finally, differing results according to suicidal ideation vs. attempts of suicide may represent the underpowered nature of the reporting of suicide attempts, which may represent the presence of a high risk of type II error.

The need for clear, objective reporting of suicide risk in transgender persons, including any change attributed to gender-affirming treatment, is highlighted further by the immense difficulty psychiatry as a field has in accurately predicting suicide risk. Even for at-risk populations, suicide attempts and parasuicidal behaviors are statistically rare enough to make it “impossible to predict on the basis of risk factors either alone or in combination” one’s risk of suicide [ 65 ].

A dearth of high-quality studies that evaluate outcomes in suicide following gender-affirming treatment poses severe limitations on the extent of claims made during the informed consent process for gender-affirming treatment. An abundance of claims that are not backed by evidence does not represent quality empirical evidence but rather guidelines endorsed by various medical organizations. Just as in practice guidelines for the assessment and treatment of patients at risk for suicide, “practice guidelines do not represent the standard of care, much less for a fact-specific case in litigation” [ 66 ].

Clinical judgment, rather than an indiscriminatory tabulation of risk-enhancing factors for suicide, will ultimately be needed, as “no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior” [ 65 ]. Risk-enhancing factors for suicide may act in a synergistic manner, with mood disorders, substance use, physical and sexual abuse, minority sexual orientation, disturbed family relationships, parental psychopathology, and various precipitating stress events [ 67 ] leading to near-infinite permutations of suicide risk that is ultimately expressed and unique on an individual level. This is especially the case for TGD individuals, for they constitute “heterogeneous groups of individuals with multiple intersecting identities” [ 20 , 59 ] that may contribute to different levels of risk for suicide.

Such permutations of suicide risk reinforce the need to control for various confounders, which is pervasively lacking in the literature to date. Most studies have ignored complex relationships among various risk factors for suicide, despite literature that suggests a nuanced intersection of these factors with suicide, such as victimization and substance use [ 24 ]. Given the heterogeneity of risk factors for this population [ 20 , 59 ], adequate control for confounding variables is needed to represent as accurately as possible the variance that can be attributed to gender-affirming treatment on suicide-related outcomes for transgender individuals as a whole and according to other defining characteristics.

In addition to trauma and abuse, other psychosocial stressors, “such as sudden unemployment, interpersonal loss, social isolation, and dysfunctional relationships, can increase the likelihood of suicide attempts as well as increase the risk of suicide” (“Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors,” 2006). It is notable that Tordoff et al. (2022) reported that conflict with caregivers over gender identity did not have a statistically significant relationship with thoughts of suicide, whereas Glynn et al. (2016) reported a statistically significant increase in suicidal ideation for those with less affirmation by one’s family. Additionally, Almazan and Keuroghlian (2021) reported lifetime suicide attempts and thoughts of suicide were not statistically significant with familial rejection as a covariate, potentially meaning that familial rejection accounted for some of the variances in suicide risk. The variety of findings regarding any potential effect of familial conflict on suicide may represent type I error, the unreliability of thoughts of suicide as a measure compared to suicide attempts, and/or the heterogeneous nature of the TGD population.

The collection of data that includes long-term follow-up is ideally suited to take into account the effects of a transgender individual’s time course, which may include a “honeymoon period” after receiving gender-affirming treatment [ 34 ]. Equally important is the controlling of time elapsed before and after gender-affirming treatment with regards to suicidality; otherwise, the number of suicide attempts or frequency of thoughts of suicide may be falsely lowered if the relative time after gender-affirming treatment is less than the pre-treatment period. However, the majority of studies did not control for the amount of time elapsed.

Limitations

The limitations inherent in a narrative review format are noted, particularly the absence of a second, independent reviewer for the inclusion and exclusion of studies as well as the lack of a systematized evaluation of publication bias and methodological rigor. Moreover, a single database was utilized, albeit with fairly extensive search criteria. Future systematic and/or scoping reviews are needed. Finally, this review may have limited generalizability. The studies included in this review span multiple countries, cultures, and decades; furthermore, TGD individuals comprise a heterogeneous group.

Conclusions

There is a need for continued research on suicidality outcomes following gender-affirming treatment. Future research that incorporates multiple measures of suicidality and adequately controls for the presence of psychiatric comorbidity, substance use, and other suicide risk-enhancing factors is needed to strengthen the validity and increase the robustness of the results. There may be implications for the informed consent process of gender-affirming treatment given the current lack of methodological robustness of the literature reviewed.

Acknowledgments

I wish to thank Dr. Glatt and Dr. Slutzky for their suggestions and advice.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

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Gender reassignment and the role of the laboratory in monitoring gender-affirming hormone therapy.

1. Introduction

3. gender development, genesis of gender incongruence, 4. guidelines for gaht, 4.1. adolescent gi, 4.2. adult gi, 5. laboratory tests in transgender afab/amab individuals, 5.1. red blood cell indices, 5.2. renal function, 5.3. liver enzymes, 5.4. lipids, 5.5. cardiac biomarkers, 5.6. reproductive hormones, 5.7. ferritin, 5.8. prostate specific antigen.

5.9. Laboratory Test Reference Intervals for Transgender Population

6. electronic medical record systems (emr), 7. gaht and other laboratory markers, 7.1. risk of venous thromboembolism in amab people, 7.2. hyperprolactinemia, 7.3. other sex hormone dependent tumours, 7.4. bone mineral density, 8. gaht, vascular health and cardiovascular disease, and impact of aging in transgender adults, 9. conclusions, 10. future directions, conflicts of interest.

• Glintborg, D.; T’Sjoen, G.; Ravn, P.; Andersen, M.S. Management of endocrine disease: Optimal feminizing hormone treatment in transgender people. Eur. J. Endocrinol. 2021 , 185 , R49–R63. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hembree, W.C.; Cohen-Kettenis, P.T.; Gooren, L.; Hannema, S.E.; Meyer, W.J.; Murad, M.H.; Rosenthal, S.M.; Safer, J.D.; Tangpricha, V.; T’Sjoen, G.G. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 2017 , 102 , 3869–3903, Erratum in J. Clin. Endocrinol. Metab. 2018 , 103 , 699. Erratum in J. Clin. Endocrinol. Metab. 2018 , 103 , 2758–2759. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Coleman, E.; Radix, A.E.; Bouman, W.P.; Brown, G.R.; de Vries, A.L.C.; Deutsch, M.B.; Ettner, R.; Fraser, L.; Goodman, M.; Green, J.; et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int. J. Transgender Health. 2022 , 23 (Suppl. 1), S1–S259. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Available online: https://auspath.org.au/wp-content/uploads/2022/05/AusPATH_Informed-Consent-Guidelines_DIGITAL.pdf (accessed on 2 June 2024).
• Cheung, A.S.; Wynne, K.; Erasmus, J.; Murray, S.; Zajac, J.D. Position statement on the hormonal management of adult transgender and gender diverse individuals. Med. J. Aust. 2019 , 211 , 127–133. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Beek, F.T.; Cohen-Kettenis, P.T.; Kreukels, B.P.C. Gender incongruence/gender dysphoria and its classification history. Int. Rev. Psychiatry 2016 , 28 , 5–12. [ Google Scholar ] [ CrossRef ]
• Reyes, A.P.; León, N.Y.; Frost, E.R.; Harley, V.R. Genetic control of typical and atypical sex development. Nat. Rev. Urol. 2023 , 20 , 434–451. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Richardson, B.E.; Lehmann, R. Mechanisms guiding primordial germ cell migration: Strategies from different organisms. Nat. Rev. Mol. Cell Biol. 2010 , 11 , 37–49. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Ostrer, H.; Huang, H.Y.; Masch, R.J.; Shapiro, E. A cellular study of human testis development. Sex. Dev. 2007 , 1 , 286–292. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• She, Z.Y.; Yang, W.X. Sry and SoxE genes: How they participate in mammalian sex determination and gonadal development? Semin. Cell Dev. Biol. 2017 , 63 , 13–22. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Edelsztein, N.Y.; Valeri, C.; Lovaisa, M.M.; Schteingart, H.F.; Rey, R.A. AMH Regulation by Steroids in the Mammalian Testis: Underlying Mechanisms and Clinical Implications. Front. Endocrinol. 2022 , 13 , 906381. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Rey, R.A.; Grinspon, R.P. Normal male sexual differentiation and aetiology of disorders of sex development. Best. Pract. Res. Clin. Endocrinol. Metab. 2011 , 25 , 221–238. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Emmanuel, M.; Bokor, B.R. Tanner Stages. [Updated 11 December 2022]. In StatPearls [Internet] ; StatPearls Publishing: Treasure Island, FL, USA, 2024. Available online: https://www.ncbi.nlm.nih.gov/books/NBK470280/ (accessed on 25 August 2024).
• Eliot, L.; Ahmed, A.; Khan, H.; Patel, J. Dump the “dimorphism”: Comprehensive synthesis of human brain studies reveals few male-female differences beyond size. Neurosci. Biobehav. Rev. 2021 , 125 , 667–697. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Ruigrok, A.N.; Salimi-Khorshidi, G.; Lai, M.C.; Baron-Cohen, S.; Lombardo, M.V.; Tait, R.J.; Suckling, J. A meta-analysis of sex differences in human brain structure. Neurosci. Biobehav. Rev. 2014 , 39 , 34–50. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Lafta, M.S.; Mwinyi, J.; Affatato, O.; Rukh, G.; Dang, J.; Andersson, G.; Schiöth, H.B. Exploring sex differences: Insights into gene expression, neuroanatomy, neurochemistry, cognition, and pathology. Front. Neurosci. 2024 , 18 , 1340108. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Fine, R.D.; Olson, K.R.; Gülgöz, S.; Horton, R.; Gelman, S.A. Gender Essentialism Predicts Prejudice against Gender Nonconformity in Two Cultural Contexts. Soc. Dev. 2024 , 33 , e12720. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Mueller, S.C.; Guillamon, A.; Zubiaurre-Elorza, L.; Junque, C.; Gomez-Gil, E.; Uribe, C.; Khorashad, B.S.; Khazai, B.; Talaei, A.; Habel, U.; et al. The Neuroanatomy of Transgender Identity: Mega-Analytic Findings From the ENIGMA Transgender Persons Working Group. J. Sex. Med. 2021 , 18 , 1122–1129. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Saraswat, A.; Weinand, J.D.; Safer, J.D. Evidence supporting the biologic nature of gender identity. Endocr. Pract. 2015 , 21 , 199–204. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Foreman, M.; Hare, L.; York, K.; Balakrishnan, K.; Sánchez, F.J.; Harte, F.; Erasmus, J.; Vilain, E.; Harley, V.R. Genetic Link Between Gender Dysphoria and Sex Hormone Signaling. J. Clin. Endocrinol. Metab. 2019 , 104 , 390–396, Erratum in J. Clin. Endocrinol. Metab. 2020 , 105 , 393. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Fernández, R.; Guillamon, A.; Cortés-Cortés, J.; Gómez-Gil, E.; Jácome, A.; Esteva, I.; Almaraz, M.; Mora, M.; Aranda, G.; Pásaro, E. Molecular basis of Gender Dysphoria: Androgen and estrogen receptor interaction. Psychoneuroendocrinology 2018 , 98 , 161–167. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Steensma, T.D.; Kreukels, B.P.; de Vries, A.L.; Cohen-Kettenis, P.T. Gender identity development in adolescence. Horm. Behav. 2013 , 64 , 288–297. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Zhang, Q.; Goodman, M.; Adams, N.; Corneil, T.; Hashemi, L.; Kreukels, B.; Motmans, J.; Snyder, R.; Coleman, E. Epidemiological considerations in transgender health: A systematic review with focus on higher quality data. Int. J. Transgender Health. 2020 , 21 , 125–137. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Brierley, J.; Larcher, V.; Hadjipanayis, A.A.; Grossman, Z. European Academy of Paediatrics statement on the clinical management of children and adolescents with gender dysphoria. Front. Pediatr. 2024 , 12 , 1298884. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Claahsen-van der Grinten, H.; Verhaak, C.; Steensma, T.; Middelberg, T.; Roeffen, J.; Klink, D. Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up. Eur. J. Pediatr. 2021 , 180 , 1349–1357. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Brik, T.; Vrouenraets, L.J.J.J.; de Vries, M.C.; Hannema, S.E. Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch. Sex. Behav. 2020 , 49 , 2611–2618. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Steininger, J.; Knaus, S.; Kaufmann, U.; Ott, J.; Riedl, S. Treatment trajectories of gender incongruent Austrian youth seeking gender-affirming hormone therapy. Front. Endocrinol. 2024 , 15 , 1258495. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Panagiotakopoulos, L. Transgender medicine—Puberty suppression. Rev. Endocr. Metab. Disord. 2018 , 19 , 221–225. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Halasz, G.; Amos, A. Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice. Australas. Psychiatry 2024 , 32 , 26–31. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Calcaterra, V.; Tornese, G.; Zuccotti, G.; Staiano, A.; Cherubini, V.; Gaudino, R.; Fazzi, E.M.; Barbi, E.; Chiarelli, F.; Corsello, G.; et al. Adolescent gender dysphoria management: Position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry. Ital. J. Pediatr. 2024 , 50 , 73. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Dahlen, S.; Connolly, D.; Arif, I.; Junejo, M.H.; Bewley, S.; Meads, C. International clinical practice guidelines for gender minority/trans people: Systematic review and quality assessment. BMJ Open 2021 , 11 , e048943. [ Google Scholar ] [ CrossRef ]
• Humble, R.M.; Imborek, K.L.; Nisly, N.; Greene, D.N.; Krasowski, M.D. Common Hormone Therapies Used to Care for Transgender Patients Influence Laboratory Results. J. Appl. Lab. Med. 2019 , 3 , 799–814. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• SoRelle, J.A.; Jiao, R.; Gao, E.; Veazey, J.; Frame, I.; Quinn, A.M.; Day, P.; Pagels, P.; Gimpel, N.; Patel, K. Impact of Hormone Therapy on Laboratory Values in Transgender Patients. Clin. Chem. 2019 , 65 , 170–179. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Allen, A.N.; Jiao, R.; Day, P.; Pagels, P.; Gimpel, N.; SoRelle, J.A. Dynamic Impact of Hormone Therapy on Laboratory Values in Transgender Patients over Time. J. Appl. Lab. Med. 2021 , 6 , 27–40. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Millington, K.; Lee, J.Y.; Olson-Kennedy, J.; Garofalo, R.; Rosenthal, S.M.; Chan, Y.M. Laboratory Changes During Gender-Affirming Hormone Therapy in Transgender Adolescents. Pediatrics 2024 , 153 , e2023064380. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Murphy, W.G. The sex difference in haemoglobin levels in adults—Mechanisms, causes, and consequences. Blood Rev. 2014 , 28 , 41–47. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Greene, D.N.; McPherson, G.W.; Rongitsch, J.; Imborek, K.L.; Schmidt, R.L.; Humble, R.M.; Nisly, N.; Dole, N.J.; Dane, S.K.; Frerichs, J.; et al. Hematology reference intervals for transgender adults on stable hormone therapy. Clin. Chim. Acta. 2019 , 492 , 84–90. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Humble, R.M.; Greene, D.N.; Schmidt, R.L.; Winston McPherson, G.; Rongitsch, J.; Imborek, K.L.; Nisly, N.; Dole, N.J.; Dane, S.K.; Frerichs, J.; et al. Reference Intervals for Clinical Chemistry Analytes for Transgender Men and Women on Stable Hormone Therapy. J. Appl. Lab. Med. 2022 , 7 , 1131–1144. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hashemi, L.; Zhang, Q.; Getahun, D.; Jasuja, G.K.; McCracken, C.; Pisegna, J.; Roblin, D.; Silverberg, M.J.; Tangpricha, V.; Vupputuri, S.; et al. Longitudinal Changes in Liver Enzyme Levels Among Transgender People Receiving Gender Affirming Hormone Therapy. J. Sex. Med. 2021 , 18 , 1662–1675. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Krasowski, M.D.; Hines, N.G.; Imborek, K.L.; Greene, D.N. Impact of sex used for assignment of reference intervals in a population of patients taking gender-affirming hormones. J. Clin. Transl. Endocrinol. 2024 , 36 , 100350. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Wierckx, K.; Van Caenegem, E.; Schreiner, T.; Haraldsen, I.; Fisher, A.D.; Toye, K.; Kaufman, J.M.; T’Sjoen, G. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: Results from the European network for the investigation of gender incongruence. J. Sex. Med. 2014 , 11 , 1999–2011. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Deutsch, M.B.; Bhakri, V.; Kubicek, K. Effects of cross-sex hormone treatment on transgender women and men. Obstet. Gynecol. 2015 , 125 , 605–610. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Fernandez, J.D.; Tannock, L.R. Metabolic effects of hormone therapy in transgender patients. Endocr. Pract. 2016 , 22 , 383–388. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Waters, J.; Linsenmeyer, W. The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures. Front. Nutr. 2024 , 11 , 1339311. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Greene, D.N.; Schmidt, R.L.; Christenson, R.H.; Rongitsch, J.; Imborek, K.L.; Rebuck, H.; Lorey, T.S.; Saenger, A.K.; Krasowski, M.D. Distribution of High-Sensitivity Cardiac Troponin and N-Terminal Pro-Brain Natriuretic Peptide in Healthy Transgender People. JAMA Cardiol. 2022 , 7 , 1170–1174. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Wang, J.; Taur, A.; Chen, A.; Wu, Y.L.; Lee, M.S. Sex-Specific Cardiac Troponin Thresholds in Transgender Patients With Suspected Acute Coronary Syndrome. JAMA Netw. Open. 2023 , 6 , e2337345. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Greene, D.N.; Schmidt, R.L.; Winston McPherson, G.; Rongitsch, J.; Imborek, K.L.; Dickerson, J.A.; Drees, J.C.; Humble, R.M.; Nisly, N.; Dole, N.J.; et al. Reproductive Endocrinology Reference Intervals for Transgender Women on Stable Hormone Therapy. J. Appl. Lab. Med. 2021 , 6 , 15–26. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Greene, D.N.; Schmidt, R.L.; Winston-McPherson, G.; Rongitsch, J.; Imborek, K.L.; Dickerson, J.A.; Drees, J.C.; Humble, R.M.; Nisly, N.; Dole, N.J.; et al. Reproductive Endocrinology Reference Intervals for Transgender Men on Stable Hormone Therapy. J. Appl. Lab. Med. 2021 , 6 , 41–50. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• McKinnon, E.J.; Rossi, E.; Beilby, J.P.; Trinder, D.; Olynyk, J.K. Factors that affect serum levels of ferritin in Australian adults and implications for follow-up. Clin. Gastroenterol. Hepatol. 2014 , 12 , 101–108.e4. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• de Nie, I.; de Blok, C.J.M.; van der Sluis, T.M.; Barbé, E.; Pigot, G.L.S.; Wiepjes, C.M.; Nota, N.M.; van Mello, N.M.; Valkenburg, N.E.; Huirne, J.; et al. Prostate Cancer Incidence under Androgen Deprivation: Nationwide Cohort Study in Trans Women Receiving Hormone Treatment. J. Clin. Endocrinol. Metab. 2020 , 105 , e3293–e3299. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Loria, M.; Gilbert, D.; Tabernacki, T.; Maravillas, M.A.; McNamara, M.; Gupta, S.; Mishra, K. Incidence of prostate cancer in transgender women in the US: A large database analysis. Prostate Cancer Prostatic Dis. 2024; Epub ahead of print . [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Crowley, F.; Mihalopoulos, M.; Gaglani, S.; Tewari, A.K.; Tsao, C.K.; Djordjevic, M.; Kyprianou, N.; Purohit, R.S.; Lundon, D.J. Prostate cancer in transgender women: Considerations for screening, diagnosis and management. Br. J. Cancer. 2023 , 128 , 177–189. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Irwig, M.S. Which reference range should we use for transgender and gender diverse patients? J. Clin. Endocrinol. Metab. 2021 , 106 , e1479–e1480. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Cheung, A.S.; Lim, H.Y.; Cook, T.; Zwickl, S.; Ginger, A.; Chiang, C.; Zajac, J.D. Approach to Interpreting Common Laboratory Pathology Tests in Transgender Individuals. J. Clin. Endocrinol. Metab. 2021 , 106 , 893–901. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Cahill, S.R.; Baker, K.; Deutsch, M.B.; Keatley, J.; Makadon, H.J. Inclusion of Sexual Orientation and Gender Identity in Stage 3 Meaningful Use Guidelines: A Huge Step Forward for LGBT Health. LGBT Health 2016 , 3 , 100–102. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Patel, K.; Lyon, M.E.; Luu, H.S. Providing Inclusive Care for Transgender Patients: Capturing Sex and Gender in the Electronic Medical Record. J. Appl. Lab. Med. 2021 , 6 , 210–218. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Totaro, M.; Palazzi, S.; Castellini, C.; Parisi, A.; D’Amato, F.; Tienforti, D.; Baroni, M.G.; Francavilla, S.; Barbonetti, A. Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study. Front. Endocrinol. 2021 , 12 , 741866. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Ott, J.; Kaufmann, U.; Bentz, E.K.; Huber, J.C.; Tempfer, C.B. Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Fertil. Steril. 2010 , 93 , 1267–1272. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Dix, C.; Moloney, M.; Tran, H.A.; McFadyen, J.D. Venous Thromboembolism and Estrogen-Containing Gender-Affirming Hormone Therapy. Thromb. Haemost. 2024 , 124 , 387–398. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Wilson, L.M.; Baker, K.E.; Sharma, R.; Dukhanin, V.; McArthur, K.; Robinson, K.A. Effects of antiandrogens on prolactin levels among transgender women on estrogen therapy: A systematic review. Int. J. Transgender Health 2020 , 21 , 391–402. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Wahlström, E.; Audisio, R.A.; Selvaggi, G. Aspects to consider regarding breast cancer risk in trans men: A systematic review and risk management approach. PLoS ONE 2024 , 19 , e0299333. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Pamulapati, S.; Conroy, M.; Cortina, C.; Harding, E.; Kamaraju, S. Systematic Review on Gender-Affirming Testosterone Therapy and the Risk of Breast Cancer: A Challenge for Physicians Treating Patients from Transgender and Gender-Diverse Populations. Arch. Sex. Behav. 2024 , 53 , 1969–1980. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Schagen, S.E.E.; Wouters, F.M.; Cohen-Kettenis, P.T.; Gooren, L.J.; Hannema, S.E. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. J. Clin. Endocrinol. Metab. 2020 , 105 , e4252–e4263. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Verroken, C.; Collet, S.; Lapauw, B.; T’Sjoen, G. Osteoporosis and Bone Health in Transgender Individuals. Calcif. Tissue Int. 2022 , 110 , 615–623. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Venkatesh, V.S.; Nie, T.; Zajac, J.D.; Grossmann, M.; Davey, R.A. The Utility of Preclinical Models in Understanding the Bone Health of Transgender Individuals Undergoing Gender-Affirming Hormone Therapy. Curr. Osteoporos. Rep. 2023 , 21 , 825–841. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Rothman, M.S.; Iwamoto, S.J. Bone Health in the Transgender Population. Clin. Rev. Bone Miner. Metab. 2019 , 17 , 77–85. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Rosen, H.N.; Hamnvik, O.R.; Jaisamrarn, U.; Malabanan, A.O.; Safer, J.D.; Tangpricha, V.; Wattanachanya, L.; Yeap, S.S. Bone Densitometry in Transgender and Gender Non-Conforming (TGNC) Individuals: 2019 ISCD Official Position. J. Clin. Densitom. 2019 , 22 , 544–553. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Shuhart, C.R.; Yeap, S.S.; Anderson, P.A.; Jankowski, L.G.; Lewiecki, E.M.; Morse, L.R.; Rosen, H.N.; Weber, D.R.; Zemel, B.S.; Shepherd, J.A. Executive Summary of the 2019 ISCD Position Development Conference on Monitoring Treatment, DXA Cross-calibration and Least Significant Change, Spinal Cord Injury, Peri-prosthetic and Orthopedic Bone Health, Transgender Medicine, and Pediatrics. J. Clin. Densitom. 2019 , 22 , 453–471. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• van Leerdam, T.R.; Zajac, J.D.; Cheung, A.S. The Effect of Gender-Affirming Hormones on Gender Dysphoria, Quality of Life, and Psychological Functioning in Transgender Individuals: A Systematic Review. Transgender Health 2023 , 8 , 6–21. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Bouck, E.G.; Grinsztejn, E.; Mcnamara, M.; Stavrou, E.X.; Wolberg, A.S. Thromboembolic risk with gender-affirming hormone therapy: Potential role of global coagulation and fibrinolysis assays. Res. Pract. Thromb. Haemost. 2023 , 7 , 102197. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Aranda, G.; Halperin, I.; Gomez-Gil, E.; Hanzu, F.A.; Seguí, N.; Guillamon, A.; Mora, M. Cardiovascular Risk Associated With Gender Affirming Hormone Therapy in Transgender Population. Front. Endocrinol. 2021 , 12 , 718200. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ PubMed Central ]
• Cheung, A.S.; Nolan, B.J.; Zwickl, S. Transgender health and the impact of aging and menopause. Climacteric 2023 , 26 , 256–262. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Lucas-Herald, A.K.; Bashamboo, A. Gonadal development. Endocr. Dev. 2014 , 27 , 1–16. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Available online: https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf (accessed on 2 July 2024).

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Ramasamy, I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. J. Clin. Med. 2024 , 13 , 5134. https://doi.org/10.3390/jcm13175134

Ramasamy I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. Journal of Clinical Medicine . 2024; 13(17):5134. https://doi.org/10.3390/jcm13175134

Ramasamy, Indra. 2024. "Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy" Journal of Clinical Medicine 13, no. 17: 5134. https://doi.org/10.3390/jcm13175134

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House GOP probes Biden admin over push to loosen transgender surgery guidelines for minors

by JACKSON WALKER | The National Desk

WASHINGTON (TND) — The House Oversight Committee on Tuesday announced it has launched a probe into the Department of Health and Human Services over its push to remove age restrictions for a variety of transgender procedures.

Documents released in June show that when the World Professional Association for Transgender Health (WPATH) was updating its guidelines, officials within the Department of Health and Human Services (HHS) feared a minimum age requirement for breast removals, genital surgeries and other procedures could invite political backlash. Emails included in the documents reveal Assistant Secretary for Health Rachel Levine, a transgender woman, advocated for WPATH to remove proposed age limits from the guidelines.

In one included email, Levine's then-chief of staff Sarah Boateng said both the assistant secretary and the Biden administration as a whole worried the inclusion of "specific ages" would affect access to health care for transgender youth. Boateng now serves as HHS's principal deputy assistant secretary for health.

Rep. Lisa McClain, R-Mich., wrote to Secretary of Health and Human Services Xavier Becerra to press for answers. She noted the House Oversight Committee is concerned the department "inappropriately applied pressure for changes to international pediatric medical standards."

“Considering the Biden administration’s recently concocted defense that ‘the Administration does not support surgery for minors,’ it is alarming that HHS would advocate for these policies in its communications with WPATH,” the letter reads . “The reality that WPATH caved to make changes to child patient care recommendations based on blatant political motivations is a stain on the credibility of WPATH and its guidelines.”

READ MORE | Detransitioner sues Planned Parenthood, other doctors over hormone therapy, breast removal

The representative closed the letter by calling for a slew of documents from HHS leaders and communications with WPATH. She included a deadline of Sept. 10.

A spokesperson for HHS did not respond to a request for comment from The National Desk (TND) Tuesday.

Former President Donald Trump’s campaign indicated last week he would call to instate felonies for doctors who perform surgeries on minors without parental consent. Prepared rally remarks of Trump also touched on introducing the death penalty for child rapists and the return of “stop and frisk” policing.

Follow Jackson Walker on X at @_jlwalker_ for the latest trending national news. Have a news tip? Send it to [email protected].