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• Gender dysphoria

Your health care provider might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. Your provider will also ask about the degree of support you have from family, chosen family and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. It involves feelings of distress due to a strong, pervasive desire to be another gender.

Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Others might instead show symptoms of a mood disorder, anxiety or depression. Or they might experience social or academic problems.

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Treatment can help people who have gender dysphoria explore their gender identity and find the gender role that feels comfortable for them, easing distress. However, treatment should be individualized. What might help one person might not help another.

Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of gender-diverse people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the chest, external genitalia, internal genitalia, facial features and body contour

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair.

Treatments are based on your goals and an evaluation of the risks and benefits of medication use. Treatments may also be based on the presence of any other conditions and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Legal age in a person's country or, if younger, following the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pre-treatment medical evaluation is done by a doctor with experience and expertise in transgender care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments This evaluation may include:

• A personal and family medical history
• A physical exam
• Assessment of the need for age- and sex-appropriate screenings
• Identification and management of tobacco use and drug and alcohol misuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo or ovarian tissue cryopreservation
• Documentation of history of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria.

The goal of behavioral health treatment is to help you feel comfortable with how you express your gender identity, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couples, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of the stress that results from experiencing prejudice and discrimination because of your gender identity (minority stress)
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A behavioral health evaluation may not be required before receiving hormonal and surgical treatment of gender dysphoria, but it can play an important role when making decisions about treatment options. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance misuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

More Information

Gender dysphoria care at Mayo Clinic

• Pubertal blockers
• Feminizing hormone therapy
• Feminizing surgery
• Gender-affirming (transgender) voice therapy and surgery
• Masculinizing hormone therapy
• Masculinizing surgery

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Mental health care. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about any anxiety or depression you're experiencing.
• Support groups. Talking to other transgender or gender-diverse people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritizing self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditation or prayer. You might find comfort and support in your spirituality or faith communities.
• Getting involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for your appointment

You may start by seeing your primary care provider. Or you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms , including any that seem unrelated to the reason for your appointment
• Key personal information , including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your health care provider
• Ferrando CA. Comprehensive Care of the Transgender Patient. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Hana T, et al. Transgender health in medical education. Bulletin of the World Health Organization. 2021; doi:10.2471/BLT.19.249086.
• Kliegman RM, et al. Gender and sexual identity. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Ferri FF. Transgender and gender diverse patients, primary care. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Nov. 8, 2021.
• Keuroghlian AS, et al., eds. Nonmedical, nonsurgical gender affirmation. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Nov. 8, 2021.
• Coleman E, et al. Surgery. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Version 7. World Professional Association for Transgender Health; 2012. https://www.wpath.org/publications/soc. Accessed Nov. 3, 2021.

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Is Counseling Needed Before Gender Transition?

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• Psychological: Female

For people with  gender dysphoria,  transitioning from one’s birth gender to their desired gender can be a big step. It can involve hormonal treatment as well as surgery. Some professionals recommend a mental health screening and psychotherapy beforehand as part of the process. But is that really necessary?

The AMA Journal of Ethics discussed the debate in a recent commentary.

On one hand, counseling can help patients better understand the complex procedures and the adjustments that will be needed, even if one has been living as their desired gender for a while. Also, many view gender reassignment surgery as permanent, and patients need to be prepared.

On the other hand, many patients are confident about their decision and see no reason for a mental health professional to intervene or approve the transition. Others feel that the transition can be modified if they change their mind, even if a complete reversal is not possible.

According to the commentary, the World Professional Association for Transgender Health (WPATH) advises mental health screenings and recommends psychotherapy before any body modifications are made. However, such decisions could be made on a case-by-case basis.

It is still important for patients to provide informed consent before any hormonal or surgical procedure is conducted, acknowledging that they understand the procedures, the risks and benefits, consequences, and alternatives, the commentary noted.

AMA Journal of Ethics

Murphy, Timothy F., PhD

“Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?”

(November 2016)

http://journalofethics.ama-assn.org/2016/11/ecas2-1611.html

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Transgender Counseling and Letter Recommending Hormone Replacement Therapy

How a counselor, therapist, diagnostician or psychologist provides professional care to transgender individuals who seek assistance in gender reassignment..

Counselors may utilize the  Standards of Care (SOC) . The Standards of Care provide clinical guidance to healthcare professionals. These guidelines are flexible and be tailored uniquely to each client. Once a counselor has found that you are mentally prepared to begin HRT (Hormone Replacement Therapy), you will receive two letters. One letter will be a recommendation for hormones. The other letter will be for surgery. Sometimes therapists combine the letters into one. The Standards of Care are helpful to look over because they are the standard guidelines professionals follow for sexual transition: The minimum amount of therapy required by these standards is 3 months. Keep in mind that they are merely guidelines, but they do seem to be adhered to fairly strictly. The therapists judgments stem from your mental readiness to start transitioning. It is the therapists responsibility to make sure that you are emotionally ready to take on such a huge endeavor. She/He needs, among other things, will make sure that:

• You have conquered any alcohol/drug addictions
• Gender reassignment is not for occupational reasons
• You understand about negative and positive side effects
• Transitioning will help, not hurt you

Learn more about the Standards of Care .

The Cost of Transgender Counseling

The price of counseling differs drastically from one therapist to another. The cheapest routes will include community counseling clinics and programs for the financially disadvantaged. Many therapists work on a sliding scale based on income. Also, check with your insurance provider to learn about their mental health coverage.

Age Restrictions

There is no minimum age that is required to begin the female to male gender reassignment process. However, minors must have consent from a parent or legal guardian.

Finding a therapist who is familiar with Gender Identity Disorder and/or the female to male identity

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• If all else fails open the yellow pages and start making phone calls. Therapists network with one another to get clients and they may give you numbers to other therapists that may be of help.
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Duke Health offers a comprehensive array of health services to transgender, gender-diverse, nonbinary, and gender-nonconforming people. Our team of experts is trained to provide high-quality, compassionate care to individuals who are considering transitioning, going through the process, or have already completed their transition and require ongoing care. Many of our providers are members of the World Professional Association for Transgender Health (WPATH) , a non-profit, professional organization devoted to transgender health.

Call us at 919-660-LGBT (660-5428) to make an appointment or click on the icon below to chat to a live agent from 8:00 am-12:00 pm and 1:00 pm-5:00 pm, Monday through Friday.

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Infertility Treatment and Fertility Preservation We support LGBTQ+ people who want to start a family. The first step is a consultation to fully understand your health and priorities for family planning so our fertility specialists can tailor a care plan to meet your needs. It is important to understand your reproductive potential and plan ahead if you are currently transitioning or planning to in the future. Your planning process may include freezing eggs or sperm. Research has shown that both can be frozen and safely preserved, so you’ll have them available when you’re ready.

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Gender-Affirming Hormone Therapy Our specially trained endocrinologists and family care providers provide gender-affirming hormone therapy to help transgender adults (ages 18 and older) achieve the changes they seek and live healthy, fulfilling lives. ​

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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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Effective Treatments for Gender Dysphoria: Goals and Techniques

Reviewed by Laura Angers, LPC · November 27, 2020 ·

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Here's a look at gender dysphoria treatment and how it can help.

Assigned Gender Vs. Expressed And Experienced Gender

Before looking at the definition of gender dysphoria, it helps if you know what assigned and experienced gender is.

Your assigned gender is the gender you were proclaimed to be at birth. Perhaps a doctor or midwife looked at you and told your parents whether you were a boy or girl. Or maybe your parents made that determination themselves. They treated you as that gender as you grew up. They probably dressed you in the typical clothes for that gender, encouraged you to behave as that gender, and discouraged you from participating in the usual activities of the other gender.

Your experienced or expressed gender is the gender you feel inside. It's aligned with the gender roles that feel right to you. And it's the gender that society associates with the types of behavior that you feel natural doing. When you and others accept your experienced and expressed gender, you can feel comfortable in your skin.

Gender Dysphoria Definition

Gender dysphoria can happen when there's a mismatch between the gender you were assigned at birth and your own experiences of gender. Your body parts may indicate that you're male or female, but you feel strongly that you're the opposite. The dysphoria part refers to a sense of discontent or unhappiness with your biological gender and the gender roles you're expected to conform to in society. The dysphoria definition emphasizes the distress caused by the mismatch between assigned gender and experienced gender.

Gender Dysphoria Vs. Gender Identity Disorder

In the past, transgender people were often diagnosed with a gender identity disorder. But psychology experts realized that this diagnosis could be harmful. It suggests that it's your gender identity that's the problem. It seems to say that if you don't identify with your assigned gender, there's something wrong with you. And, gender identity disorder gives the impression that you need to think, feel, and behave as society expects you to because of your assigned gender.

That's why the DSM 5 changed the name and criteria for diagnosis. Now, the term used is gender dysphoria. What's the difference? The phrase "gender dysphoria" recognizes that the real problem is the distress you feel about the mismatch. Part of the distress may come from ideas you and your family have about gender you or they think you should be. Also, you and they may be uncomfortable with how you express gender. Another part of the discontent might be because of the social stigma attached to being transgender. In any case, the new term recognizes that your gender identity isn't a problem.

Is Gender Dysphoria A Mental Illness?

As defined in the Diagnostic and Statistical Manual, the  DSM-5, gender dysphoria  is listed among all the recognized mental disorders. After all, the purpose of the manual is to guide the diagnosis of mental conditions.

However, the label "disorder" was eliminated in this version of the DSM to reduce the stigma of having that diagnosis. And in the sense that mental illness indicates an abnormal way of thinking, feeling, or behaving, gender dysphoria really can't be considered a mental illness.

Again, it's important to remember that it's the distress or dysphoric experience of being transgender, making it a mental problem. If you're transgender but have no dysphoric feelings, thoughts, or behaviors about it, you don't have dysphoria.

DSM Gender Dysphoria Criteria

The DSM 5 lists specific criteria for gender dysphoria to help mental health professionals recognize and diagnose this condition. Receiving this diagnosis means that two things are true. First, your assigned gender is different from the gender you experience and express. Second, you have distress about that and may even have problems functioning because of it.

Furthermore, you must have at least two of the following symptoms, and they must last for at least six months.

• There's a significant difference between your experienced gender and your primary or secondary sex characteristics.
• You strongly wish you could eliminate your current primary and secondary sex characteristics.
• You have a deep desire to have the primary or secondary characteristics of another gender.
• You strongly want to be the other gender.
• You want others to treat you as the other gender.
• You feel confident that you behave and react the same as people of the other gender usually do.

Gender Dysphoria Treatment

Treatment for gender dysphoria  is designed to help you deal with or overcome your dysphoric experience of gender. It can consist of various types of individual or group therapy. This treatment won't change who you are. It has different goals and outcomes you may not expect.

Goals Of Treatment

The goals of treatment for gender dysphoria all have to do with coming to terms with your gender. Here is a brief list of some of the goals you might work towards psychological treatment for gender dysphoria.

• Explore Your Gender Identity – Maybe you don't know what your gender identity is. You might have had conflicting feelings or experiences related to gender. In therapy, you have the freedom to question your assigned gender without any requirement to change or not change your gender identity. And, you can explore what it means to you to be male or female.
• Accept Yourself As The Gender You Feel Inside – With society pushing you to behave as your assigned gender, it might be hard to accept yourself for who you are inside. You may criticize yourself constantly or feel like a failure when you don't conform to others' wants. Before you can deal with their disapproval, you have to learn to love yourself like your gender. Therapy can help you come to terms with the mismatch and even boost your self-esteem.
• Deal With Family And Society's Expectations. It can be disheartening when those around you expect you to behave differently than you do. Even if you don't express the gender you feel inside, knowing that others expect you to can be very upsetting. But as you learn to deal with their disapproval, you can begin to feel more confident in being who you are.
• Learn How To Handle Bullying  – Often, transgender people are the targets of bullies. It's a common experience to be hurt physically or emotionally by people who don't understand gender differences. So, knowing how to deal with situations where you're being bullied can make your life easier and less distressing.

• Express Your Dysphoric Feelings In A safe, Non-Judgmental Environment – One goal of therapy is to support you. This therapy aspect is often critical because so many transgender people face disapproval and are even shunned by their family and society; having a place to express yourself freely can be invaluable.
• Explore Options For Expressing And Living Your Gender Identity –Your therapist can provide information and educational materials about the ways you might choose to approach gender incongruence. They can offer info on topics like living as the other gender, getting gender reassignment surgery, and each option's psychological challenges. They can also support you as you talk through your reactions to each of these solutions.
• Manage The Coming Out Process – If you decide to let others know that you're transgender, you may be afraid of what will happen. And indeed, you may face numerous challenges during this crucial period. A counselor allows you to express yourself and helps you deal with your fears. They can offer insights about what to expect and offer support during this time.
• Help With Living According To Your True Gender Identity –If you have gender reassignment treatment, you'll probably spend some time living as the other gender before making the transition. Even if you don't intend to make a medical transition, you might decide to live in a way that's congruent with your gender identity. This change may involve many practical dilemmas and adjust to societal attitudes about how you choose to live. A therapist can help you cope with and manage your new living situation.
• Deal With Gender Reassignment – At some point, you may decide to make a physical transition to your experienced gender. If you do, therapy can help you deal with any mixed feelings or fears you have about changing your gender through medical procedures.

Treatment Methods

Many of the same treatment methods are used for gender dysphoria as for many other mental problems. The difference is that the subjects you deal with in therapy will be different. But the techniques used may be about the same.

The exception, of course, is gender reassignment. Medical treatment for gender dysphoria usually consists of the triadic treatment model. The triadic treatment has three parts: living as your true gender identity, taking hormones, and getting surgery to change your sex characteristics.

As for psychotherapy methods, your counselor may help you using a variety of techniques and therapy types. These include:

• Individual counseling
• Couples, family, or group therapy
• Educational counseling
• Coping skills development
• Insight therapy

"Do I Have Gender Dysphoria?"

You might be well aware there's a mismatch between your assigned gender and your experienced gender. Or perhaps you're only questioning whether you have gender identity issues. Even if you are sure of your gender identity, though, you may not be sure that it's causing you significant distress.

One way to find out is to take a  gender dysphoria test . An online screening test for gender dysphoria is a confidential and objective assessment of your symptoms. It isn't a diagnosis, but it can reveal the need to explore the possibility further. Suppose the results show you probably have this condition. In that case, you can then consider working with a mental health professional to resolve your gender issues.

Gender dysphoria is a condition that can cause significant distress. The first step to relieving your fears or discomfort is to find out if you have the symptoms of gender dysphoria. If you do, you can move on to seeking mental health help for diagnosis and treatment.

In the end, whatever your gender identity, you can learn many ways to deal with the feelings that come with it. With the best treatment for you, you can learn to accept your inner gender identity and live the life that matches your gender experience.

Frequently Asked Questions (FAQs)

What is the most effective treatment for gender dysphoria? How do you cure gender dysphoria? What happens if you don't treat gender dysphoria? What medications are used for gender dysphoria? Can gender dysphoria go away? Can gender dysphoria be caused by trauma? At what age is gender dysphoria most common? How do you shower with dysphoria? What are the signs of gender dysphoria? Can you self-diagnose gender dysphoria?

Find out if you have Gender Dysphoria

Take this mental health test. It's quick, free, and you'll get your confidential results instantly.

Mental health conditions are real, common, and treatable. If you or someone you know thinks you are suffering from gender dysphoria then take this quick online test or click to learn more about the condition.

Take test Learn more

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Gender reassignment therapy

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Gender reassignment therapy is an umbrella term for all medical procedures regarding gender reassignment of both transgender and intersexual people. (Sometimes also called sex reassignment, as it alters physical sexual characteristics to be more in line with the individual’s psychological/social gender identity, rather than vice versa.)

Gender reassignment therapy consists of hormone replacement therapy (HRT), various surgical procedures (see below), and epilation for transwomen, that is permanent hair removal on the face and body is accomplished with electrolysis or laser hair removal.

Transsexual people who go through gender reassignment therapy usually change their social gender roles, legal names, and legal sex designation, in addition to undergoing the medical procedures discussed in this article. The entire process of change from one gender presentation to another is known as transition.

Sex reassignment surgery is the most common term for what would be more accurately described as genital reassignment surgery or genital reconstruction surgery . This refers to the procedures used to make male genitals in to female genitals and vice versa. Sex reassignment surgery, or SRS, can also refer to any surgical procedures which will reshape a male body into a body with a female appearance or vice versa.

Surgical procedures related to gender reassignment

For trans men , who transition from female to male:

• Sexual reassignment surgery female-to-male
• Mastectomy is the removal of female breasts and, in case of gender reassignment, the shaping of a male contoured chest.
• Hysterectomy is the removal of female internal sex organs.
• Metoidioplasty is the construction of a small penis out of the clitoris which has been enlarged by HRT
• Phalloplasty is specifically the construction of a neo-penis in transmen

For trans women , who transition from male to female:

• Sexual reassignment surgery male-to-female
• Vaginoplasty The shaping of a neo-vagina
• Penile inversion – the most common form of genital reassignment surgery.
• Colovaginoplasty – a particular form of genital reassignment surgery.
• Breast augmentation is the enlargement of breasts, which can be necessary if HRT did not yield satisfactory results.
• Facial feminization surgery

Requirements

The requirements for hormone replacement therapy vary greatly, often at least a certain time of psychological counseling is required, and so is a time of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role.

Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the opposite gender in all possible ways for at least a year (“cross-live”) prior to the start of surgery in order to assure that they can psychologically function in that life-role. This period is sometimes called the Real Life Test (RLT); it is part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for this surgery.

Most professionals in the USA who provide services to transsexual women and men follow the controversial Standards of Care for Gender Identity Disorders put forth by the Harry Benjamin International Gender Dysphoria Association. Outside the USA, many other SOCs, protocols and guidelines exist, although the Harry Benjamin SOCs are certainly the best known. There exists a significant and growing political movement to redefine the SOC, asserting that they do not acknowledge the rights of self-determination and control over one’s body, and that they expect (and even in many ways requires) a monolithic transsexual experience when in reality there are as many different ways of being transsexual as there are transsexual people. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from “making a mistake” and causing irreversible changes to their bodies that will later be regretted — though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.

Controversy

Although the overwhelming majority of individuals who undergo gender reassignment are forever happy and content living as members of their target sex, some people still believe that gender reassignment is ineffective as a treatment for transsexuality, or that it is “wrong” and/or “immoral.”

Many religious conservatives believe that physical gender reassignment is sinful, and therefore cite evidence that transsexuality can be cured spiritually or psychologically. However, substantial evidence suggests that psychological treatments for transsexuality are highly ineffective.

Although it is undeniably offensive to transsexual women and men, some people consider transsexuals to be members of the physical sex assigned to them at birth, even after they have completed all aspects of gender reassignment. Their reasoning is often based in the facts that sex chromosomes cannot be changed with the procedures currently available, and that transsexuals do not have reproductive organs. Many other people believe that an individual’s sex is determined by factors such as gender presentation, gender identity, external genitalia, and sex hormones; and therefore, they consider transsexuals to be true members of their target sex. They often point to otherwise “normal” women and men who were either born without certain reproductive organs, or had them removed, as well as the existence of people whose sex chromosomes do not match their physical sex and gender identity, such as women with Complete Androgen Insensitivity Syndrome.

In 1967, John Money, a prominent sexologist at Johns Hopkins Hospital, recommended that David Reimer , a boy who had lost his penis during a botched circumcision, be sexually reassigned and raised as a girl. Despite being raised as a girl from the age of 18 months, Reimer was never happy as a girl, and when he learned of his sex reassignment, he immediately reverted to living as a male. Money never reported on the negative outcome of Reimer’s case, but in 1997, Reimer went public with the story himself. His case, as well as several cases of intersexed infants with conditions such as cloacal exstrophy who have been reassigned and raised as females, suggest that gender identity is innate and immutable.

In 1979, when Paul McHugh became chairman of the psychiatric department at Johns Hopkins, he ordered the department to conduct follow-up evaluations on as many of their former transsexual patients as possible. When the follow-ups were performed, they found that most of the patients claimed to be happy as members of their target sex, but that their overall level of psychological functioning had not improved. McHugh reasoned that to perform physical gender reassignment was to “cooperate with a mental illness rather than try to cure it.” At that time, Johns Hopkins closed its gender clinic and has not performed any sex reassignment surgeries since then. Many people have criticized McHugh’s conclusion, often stating their belief that the purpose of gender reassignment is to make transsexual people happy and content with their bodies, not to improve their psychological functioning.

Many medical textbooks state that “significant psychological problems often persist after surgical and hormonal sex reassignment.” However, these texts do not cite reputable sources on which they base their conclusions. Much less research has been done on transsexuality than on many other conditions such as Down syndrome, Cerebral palsy, and autism. However, many people, especially transsexual people, feel that physical gender reassignment is a highly effective treatment for transsexuality, and that medical researchers should have higher priorities than transsexuality. This is especially true of those who feel that “mainstream” medical professionals who research transsexuality are attempting to find ways to cure the condition psychologically; many transsexual people feel that physical gender reassignment is a far better treatment for their gender dysphoria than any psychological treatment or other treatment to “change the mind to match the body” rather than vice versa, ever would be.

Most of the published studies regarding gender reassignment are widely believed to be biased.

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Gender-Affirming Care

• Contact Us Complete our Gender-Affirming Care Interest Form

At UC San Diego Health, you'll find providers who understand that gender-affirming care can help you live a healthier, more authentic life.

We know that getting high-quality health services can be challenging for those who are transgender or nonbinary. Look to UC San Diego Health for the most comprehensive gender health program. We are the only hospital system in San Diego to offer the full spectrum of gender-affirming services to individuals 18 years of age and older. 

We want to help you feel comfortable through your gender journey. That's why we offer coordinated care with a licensed clinical social worker to help you navigate our services in a way that meets your individual needs.

How to Become a Patient

To become a patient, you can work with our Gender Health team or can make an appointment directly with the appropriate doctor on the list below. If you have an HMO insurance plan, you will need your primary care physician to refer you to a specialist. You may also select a primary care physician with our gender health program.

Care Coordination

Rai Khamisa, LCSW (they/them), is our gender health program director. Rai is a POC gender-affirming licensed therapist who takes pride in serving the communities they inhabit. They have built their career on working with queer and trans/gender diverse individuals, BIPOC communities, and universities and businesses that want to provide a more affirming environment for gender diverse individuals.

They continue to work towards reaching communities that identify in the LGB+, trans, gender diverse, and BIPOC spectrums through therapy and case management, supervision, program development and training.

Working closely with patients, medical staff, our gender health insurance specialist and other program managers, they hope to earn your trust in supporting you during your gender journey. For more information, email us at [email protected] or call 619-543-3633 .

Key Services and Providers

Primary care.

Primary care is essential for everyone to meet their health goals and stay up to date with routine health maintenance. We offer holistic, gender-affirming primary care, including hormone therapy and referrals to specialists — everything you need to achieve your gender health goals.

Primary Care Providers

• Jill S. Blumenthal, MD
• Julie Çelebi, MD
• Tari L. Gilbert, MSN, FNP-BC
• Matthew MacFarlane, MD, MA, AAHIVS
• Marlene Millen, MD
• Eric G. Mendez, MD
• Amy Sitapati, MD
• Gabriel Wagner, MD

Psychiatry and Mental Health

We believe in treating the whole patient, which includes mental as well as physical health. We provide comprehensive mental health care and emotional support along the way, including therapy, medication management, and letters of readiness for surgery.

Psychiatrists

• David J. Grelotti, MD
• Andres Ricardo Schneeberger, MD
• Jessica L. Thackaberry, MD

Dermatology

Our dermatologists provide laser treatment for unwanted hair on the face and body, in addition to treating an array of skin conditions such as acne and hair loss.

Dermatologists

• Arisa Ortiz, MD, FAAD (not currently accepting Medi-Cal insurance)
• Swati Kannan, MD, FACMS, FAAD

Ear, Nose & Throat

Specialized therapy and vocal cord surgery can help you communicate in a way that is more aligned with your gender identity.

For Tracheal Shaves and Vocal Cord Feminization:

• Andrew Vahabzadeh-Hagh, MD
• Philip Weissbrod, MD

For Vocal Coaching:

• Andi Docktor, MA, CCC-SLP
• Ben Schiedermayer, MS, CCC-SLP

Endocrinology

Gender-affirming hormone therapy can help align your body with your gender identity. Our providers are guided by your goals to help select the best hormone regimen that can work for you.

Endocrinologist

• Ravi M. Iyengar, MD

We can help you learn about your options to preserve fertility if that is a goal for you. This includes egg preservation as well as sperm banking.

For Egg Preservation:

• H. Irene Su, MD, MSCE , Reproductive Endocrinologist

For Sperm Banking:

• T. Mike Hsieh, MD
• Darshan Patel, MD

Obstetrics & Gynecology

Removal of the uterus, cervix, ovaries and vagina can often be done with minimally invasive techniques. We can also meet your needs for overall reproductive health.

Gynecologist

• Jorge Alvarado, MD, FACOG

Obstetrician

• Gina R. Frugoni, MD

Plastic Surgery

Plastic surgery can help you alter your face and body to align with your gender. This includes body contouring, facial reconstructive surgery, and chest or “top” surgery to remove breast tissue or enhance breast appearance. 

 (For more on genital or “bottom” surgery, see Reconstructive Urology below.)

For Body Contouring:

• Priya Lewis, MD
• Ahmed S. Sulliman, MD
• Anne M. Wallace, MD

For Facial Feminization and Masculinization:

• Amanda A. Gosman, MD
• Jay Xue, MD

For Breast Augmentation and Mastectomies (Top Surgeries):

For Vaginoplasty and Phalloplasty (Bottom Surgeries):

Reconstructive Urology

Our gender-affirming pelvic or “bottom” surgery services include vaginoplasty (penile inversion, peritoneal and intestinal), vulvoplasty (zero or shallow depth), metoidioplasty, robot-assisted hysterectomy with vaginectomy, and nonbinary options.

Reconstructive Urologist

• Jennifer T. Anger, MD, FPMRS, MPH

Our urologists perform orchiectomies (removal of the testes) and can manage urologic complications that might occur with gender-affirming surgery.

They also address sexual health and various testosterone formulations.

• Christopher Ceriale, MSPAS, MPH, PA-C
• Jason Woo, MD  

Photographs

Due to privacy and ethical considerations, we do not publish photos of our patients on our website. During your consultation, you will have the opportunity to view pre-operative and postoperative patient photographs.

Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

American Society of Plastic Surgeons. Gender confirmation surgeries .

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

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

POWER OUTAGE: Power is temporarily out at Lincoln Avenue Health Center, including the lab. If you have an appointment, we will contact you to reschedule or arrange a virtual visit if appropriate. Patients seeking lab services should reschedule or visit another lab location .

Transgender Hormone Therapy

Transgender men and women desire a permanent identity as a member of the gender with which they identify. This transition usually involves hormonal therapy and may also involve surgery.

We offer hormonal therapy for transgender individuals. People seeking transgender surgery are referred to well-established health care facilities that specialize in this procedure.

Hormonal Therapy

Transgender hormonal therapy (also called hormonal reassignment) allows development of secondary sexual characteristics that reflect the person's preferred gender identity.

Hormonal therapy for transgender people replaces the hormones naturally occurring in their bodies with those of the other sex.

• Woman-to-man hormonal treatment (testosterone treatment) is provided to promote male characteristics, such as a male pattern of body hair, a male voice and a male physical shape. The treatment also results in stopping monthly menstruation.
• Man-to-woman hormonal treatment is provided to inhibit male characteristics and promote feminine characteristics, such as breast formation and elimination of body hair growth.

Both male hormones (androgens) and female hormones (estrogens) are present in men and women alike, but in vastly different amounts. Giving the right amount of the right hormone is important in the life-long management of transgender hormonal therapy.

Psychological Evaluation

To obtain sex reassignment therapy, a full psychological or psychiatric evaluation by a certified professional will be performed prior to the start of hormonal therapy. This is important to ensure that the diagnosis of transgender re-assignment is not clouded by an underlying psychiatric disorder. 

A local transgender program called Pathways  offers professional and supportive programs dealing with issues of gender identity. Pathways also offers psychiatric evaluations to program participants, as well as information, guidance about resources and peer group support.

Therapy Based on Guidelines

Initial care includes a physical exam and blood test to check the individual’s overall health. Hormonal therapy is geared to an individual’s goals and therapy is monitored by clinical response and blood tests. Therapies are adjusted as needed based on response. Hormones are given as oral or injected medications.

Therapy is based on care standard guidelines established by The Endocrine Society called Endocrine Treatment of Transgender Persons. The guidelines were developed by a task force of content experts and co-sponsored by the European Society of Endocrinology, European Society of Pediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and the World Professional Association for Transgender Health. The guidelines address treatment of adolescents, hormonal therapy for transgender adults, long-term care and sex re-assignment surgery.

People who desire transgender hormonal therapy are encouraged to see a trained medical professional, who will prescribe the right medications and monitor your care over time. The physician carefully watches for complications as you slowly begin taking an increased level of hormones.

Physicians throughout Wisconsin refer their patients to us for transgender hormonal therapy. We share our expertise with these community physicians so they can continue local care for their patients.

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Gender dysphoria

Gender dysphoria is a term used to describe the distress a person feels when their gender does not match the sex they were assigned at birth. Here we look more closely at what gender dysphoria is and how counselling can be a support.

There are lots of people who feel this way. While gender dysphoria is not a mental health problem, it can cause the person a great deal of stress. Not feeling able to express your true identity, along with living in a society filled with misunderstanding and stigma may affect your wellness.

In this video, Dr Dane Duncan Mills discusses gender identity, what to look for in a therapist and where to find support.

What is gender dysphoria?

Gender dysphoria is the distress someone feels when they are assigned a gender at birth, but identifies as another. For example, a person assigned male at birth may identify as female or vice versa. Some people may not identify with a gender at all or may identify as gender fluid.

People who feel this way are most commonly known as ‘transgender’ or ‘trans’ however, we understand that trans people self-identify in many ways. Throughout this page, we will use ‘trans’ as an inclusive term, which embraces trans, trans* , transgender, gender nonconforming and gender variant, among others.

Non-binary gender identity

People can also describe themselves as ‘non-binary’, which is when they do not feel they are male nor female. Non-binary also embraces those who identify as androgyne, thirdgender and polygender, who are not comfortable thinking of themselves as simply male or female. They may identify as a combination of the two, or neither.

Is gender dysphoria a disorder?

Although gender dysphoria is listed in the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), it is not considered a disorder or mental illness. Originally referred to as gender identity disorder, this was replaced by gender dysphoria with the release of the DSM-5 in 2013.

Since 2019, the World Health Organization (WHO) has stated that gender incongruence is no longer classified under mental and behavioural disorders. WHO officials say that is it ‘not actually a mental health condition’ since the introduction of the International Classification of Diseases 11 (ICD-11). These changes were made to help reduce stigma, as well as due to new, better understandings of gender incongruence.

Since this update, many health professionals and organisations worldwide have changed how they talk about gender dysphoria to reflect this, including the NHS, which states : "Gender dysphoria is not a mental illness, but some people may develop mental health problems because of gender dysphoria.”

Signs of gender dysphoria

It’s common for the signs of gender dysphoria to show at a very early age. Children may refuse to wear certain clothes or dislike taking part in typical boys or girls’ activities. Other early behaviours may include:

• insisting that they are of the opposite sex
• wanting to wear clothes typically worn by the other sex, and disliking or refusing to wear clothes typically worn by their sex
• insisting or hoping that their genitals will change
• feeling extreme distress at puberty and the physical changes that will occur
• feelings of anxiety and depression

In some cases, these behaviours are just a part of the child growing up. Yet if the feelings of gender dysphoria are still present as they go through their teenage years and into adulthood, it is likely that it is not a stage of development, and further support may be needed.

While many people with gender dysphoria will feel this way during early childhood, this isn’t always the case. Some people may not recognise their feelings for what they are until adulthood, or have simply learned to suppress and hide the feelings to avoid peer and family rejection while growing up.

Puberty forces changes on a body that can feel particularly uncomfortable. Unwanted changes are happening, so while a child may have enjoyed being androgynous growing up, the secondary sex characteristics of puberty can be very distressing.

I sat down on the arm of the sofa, head feeling like it was about to explode, when it hit me. A strong, resonate thought that shook me to the core: I don’t want to be a girl anymore. - Read Zach's story .

If you are a teenager or adult, whose feelings of gender dysphoria started in childhood, you may now feel like you have a much clearer sense of your identity and how you want to deal with it. You may be certain that your gender identity is at odds with your assigned sex, a strong desire to hide or be rid of the physical signs of your sex, such as breasts and body hair.

Only you can ever say how you feel. Some people will know from a very young age, while others will feel like they don’t ‘fit’ with members of their sex, but do not know what to do, or how to tell people how they feel. Many people will keep their thoughts and feelings to themselves, living a life and body they aren’t happy in.

Everyone deserves to live the life they want. This is why we are passionate about raising awareness of issues and providing people with the information and support they need.

Living with gender dysphoria

It can be very distressing to keep how you feel to yourself. Whether through lack of support, information or from fear of judgement or discrimination, living a life where you are unhappy, really, is no life at all.

Gender dysphoria is not a mental illness, however, people who experience gender dysphoria often suffer great stress as a result of not living their true identity. This is why it is so important that we speak about these issues - society needs to understand and be more aware of the feelings many people experience. Talking about it and supporting each other is the first step to breaking down the stigma and helping trans people feel more comfortable in reaching out and asking for help. Nobody should feel they have to keep quiet about who they are.

According to charity Stonewall , two in five trans people (41%) said that when accessing general health care services in 2017, healthcare staff lacked understanding of trans health needs.

If a person has made the decision to change their gender identity, this is known as ‘transition’. This enables them to express themselves in line with their gender identity, perhaps by choosing a new name and changing their appearance, like changing their hair or wearing different clothes. The way in which individuals express themselves will vary from person to person, everyone is different and these changes take time.

The Equality Act 2010 

Gender reassignment is a protected characteristic under the Equality Act 2010. This means you are protected by law if you are a victim of harassment or discrimination in the workplace, and wider society. For more information on the Equality Act 2010 and the laws against hate crime, visit our discrimination page.

Coming out as transgender

Telling people about your sexuality or gender identity is typically called ‘coming out’. Coming out is an incredibly individual process and not necessarily a one-off event. Lesbian, gay, bisexual and trans people may have to come out many times during their lives and sadly, many people will face challenges when doing so.

How you come out will depend what you feel comfortable with. For example, you may feel comfortable speaking about your gender identity with your close friends, but not with your family. 

If you have decided that you are ready to tell people, it can help to sit and really think about how and where you want to tell them. Depending on who you talk to, they may have questions, so be prepared to answer them, or tell them if you’re not ready.

If they react badly, remember that they may just need some time to absorb what you’ve told them. While you can’t predict how people will respond, if you have told a close friend you trust, the chances are they’ll be pleased you’ve shared something so personal and support you. 

Don’t feel under pressure to come out - take your time. Only you will know when you’re ready to talk and asking for help isn’t easy. If you feel ready to come out but are unsure of how to broach the subject with loved ones, visit Stonewall for more information.

Some people need time to think and consider to go from one step to the other (for example between coming out to one person and the next), whilst some like to act fast and get results once the decision has been made (coming out at school, changing names, writing to the clinic – all almost in one day). Whatever is your way – it’s the right way. - Read more tips for transitioning teens by counsellor Anna Jezuita (MBACP)

Treatment for gender dysphoria - the next steps

Treatment for gender dysphoria aims to help people live the way they want to, as the gender they identify with. What this means will vary for each person, and is different for children, young people and adults.

The first step is to speak to a professional. Whether this is your GP, a psychotherapist or a counsellor, if you have come to the decision that you want further treatment, professional support is essential.

Children and young people

Under 18s will typically be referred to a specialist child and adolescent Gender Identity Clinic (GIC), where staff will carry out a detailed assessment, to help determine what support they need. Treatment will vary depending on the results of the assessment and the age of the child, though options include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• regular reviews
• hormone therapy

Also, know that schools have a legal duty to support trans students (even single-sex schools) and many are doing so very well. If you or your child is at school and would like support outside of a professional environment, consider speaking to the student support services if available, or your teacher. They will be able to explain the support available and together you can decide on the next steps.

Adults with gender dysphoria should be referred to a specialist adult GIC. As with children and young people, these clinics can offer ongoing support and advice, assessments and treatment. This may include:

• mental health support, such as counselling
• cross-sex hormone treatment
• speech and language therapy
• peer support groups

Some people find that the support and advice from a specialist clinic is all they need to feel comfortable in their transition. Others will need more extensive treatment, such as a full transition to the opposite sex. The level of treatment you receive is completely down to you - only you know what you need and how you feel.

Hormone therapy

Hormone therapy is prescribed to help make individuals more comfortable with themselves - in terms of both physical appearance, and how they feel. If undergoing hormone therapy, individuals will take the hormone of their preferred gender. Whether testosterone or oestrogen, the hormones will start the process of changing the body into one that is more male or female.

Typically, this will be a lifelong treatment, even if you have had genital reconstructive surgery.

Social gender role transition

If you are considering a transition that requires surgery, you are typically required to live in your preferred gender identity full-time for at least one year before surgery. This is known as ‘social gender role transition’ (previously known as ‘real life experience’) and will help in confirming whether surgery is the right option for you.

Once you have completed your social gender role transition, and you and your care team are confident you are ready, you may decide to go ahead with the surgery.

Counselling for gender dysphoria

As we said, gender dysphoria is not a mental illness . Yet, living a life that you feel isn’t yours can be detrimental to your mental health and well-being. The confusion, the fear of judgement, the isolation, the stress. All of these things can affect a person’s mental health and if untreated, can lead to further problems. 

Talking is an incredibly helpful tool, wherever you are in your journey. Of course, this can be easier said than done, and sadly, stigma and misunderstanding is still present in today’s society. If you’re not ready to talk to friends and family, seeking professional support can be an option.

A counsellor experienced in gender dysphoria and trans people will have an understanding of what you are going through, and the options available to you. They can offer you a safe place to talk, free of stigma and judgement, and without shame. In the counselling room, you can be you.

On Counselling Directory, we have a Proof Policy in place in which professionals must provide proof of qualifications and insurance or membership with a professional body. We encourage all members to provide information on their experience and specialisms on their profiles, so to help you understand their way of working, and if they are the right person for you.

Know that all counselling professional bodies have outlawed 'conversion' or 'reparative' therapies. While counsellors can offer you a safe space to explore gender dysphoria, they are not permitted to attempt to 'convert' someone's gender or sexuality.

For anyone struggling with their gender identity, I’d say identity is complex, and there is no one-size-fits-all solution. I’m still finding myself, where my masculinity/femininity sits, and how much surgery I want to undergo. My best advice is this: if it’s making you happy, keep going, and anything else, push away. - Kenny Ethan Jones

Further help

• Gendered Intelligence
• Mermaids UK
• Online safety guide for LGBTQ+ community

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Stages of Gender Reassignment

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

Lots More Information

Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

Related Articles

• How Gender Identity Disorder Works
• Is gender just a matter of choice?
• What is transgender voice therapy?
• How fluid is gender?
• Why do girls wear pink and boys wear blue?

More Great Links

• DSM-5: Gender Dysphoria
• National Center for Transgender Equality
• The Williams Institute
• American Medical Student Association (AMSA). "Transgender Health Resources." 2014. (April 20, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
• American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." 2011. (July 1, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
• AP. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 20, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
• Belkin, Lisa. "Smoother Transitions." The New York Times. Sept. 4, 2008. (Aug. 1, 2011) http://www.nytimes.com/2008/09/04/fashion/04WORK.html
• Crane, Curtis. "The Total Guide to Penile Implants For Transsexual Men." Transhealth. May 2, 2014. (April 20, 2015) http://www.trans-health.com/2013/penile-implants-guide/
• Donaldson James, Susan. "Trans Chaz Bono Eyes Risky Surgery to Construct Penis." ABC News. Jan. 6, 2012. (April 20, 2015) http://abcnews.go.com/Health/transgender-chaz-bono-seeks-penis-genital-surgery-risky/story?id=15299871Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
• Glicksman, Eve. "Transgender today." Monitor on Psychology. Vol. 44, no. 4. Page 36. April 2013. (April 20, 2015) http://www.apa.org/monitor/2013/04/transgender.aspx
• Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape Medical News. May 20, 2013. (April 20, 2015) http://www.medscape.com/viewarticle/804432
• HealthResearchFunding.org (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 20, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
• International Foundation for Gender Education. "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 20, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
• Moskowitz, Clara. "High Suicide Risk, Prejudice Plague Transgender People." LiveScience. Nov. 18, 2010. (April 20, 2015) http://www.livescience.com/11208-high-suicide-risk-prejudice-plague-transgender-people.html
• Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. 2013. (April 20, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
• Public Religion Research Institute. "Survey: Strong Majorities of Americans Favor Rights and Legal Protections for Transgender People." Nov. 3, 2011. (April 20, 2015) http://publicreligion.org/research/2011/11/american-attitudes-towards-transgender-people/#.VSmlgfnF9bw
• Steinmetz, Katy. "Board Rules That Medicare Can Cover Gender Reassignment Surgery." Time. (April 20, 2015) http://time.com/2800307/medicare-gender-reassignment/
• The Philadelphia Center for Transgender Surgery. "Phalloplasty: Frequently Asked Questions." (April 20, 2015) http://www.thetransgendercenter.com/index.php/surgical-procedures/phalloplasty-faqs.html
• U.S. Office of Personnel Management. "Guidance Regarding the Employment of Transgender Individuals in the Federal Workplace." 2015. (April 20, 2015) http://www.opm.gov/diversity/Transgender/Guidance.asp
• University of California, San Francisco - Department of Family and Community Medicine, Center of Excellence for Transgender Health. "Primary Care Protocol for Transgender Patient Care." April 2011. (April 20, 2015) http://transhealth.ucsf.edu/trans?page=protocol-hormones
• University of Miami - Miller School of Medicine, Department of Surgery, Plastic, Aesthetic and Reconstructive Surgery. "Transgender Reassignment." 2015. (April 20, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
• University of Michigan Health System. "Gender Affirming Surgery." (April 20, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
• World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf
• World Professional Association for Transgender Health (WPATH). "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide." 2015. (April 20, 2015) http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947

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• Open access
• Published: 19 August 2024

Discontinuing hormonal gender reassignment: a nationwide register study

• Riittakerttu Kaltiala   ORCID: orcid.org/0000-0002-2783-3892 1 ,
• Mika Helminen 2 ,
• Timo Holttinen 3 &
• Katinka Tuisku 4  

BMC Psychiatry volume  24 , Article number:  566 ( 2024 ) Cite this article

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With increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.

A nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.

Of the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1–6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.

Conclusions

The risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.

Trial registration number (TRN)

Not applicable (the paper does not present a clinical trial).

Peer Review reports

In gender medicine, transition refers to people with sex-discordant gender identities making changes in their lives to live in their experienced gender, socially (appearance, name, personal pronouns), juridically (identity documents) or medically (hormonal and surgical medical interventions that modify secondary sex characteristics ) . Detransition refers to people aborting their initiated transition and reversing it, totally or partially, to live in a sex-accordant role by reversing the abovementioned steps of transition.

Recent decades have witnessed an exponential increase in those seeking medical interventions to support their transition (medical gender reassignment, GR), with an increasing share of younger individuals of the female sex [ 1 , 2 ]. Psychiatric morbidity among people who contact specialized gender identity services (GISs) has increased simultaneously [ 2 , 3 ] and is particularly pronounced among the youngest age groups [ 4 ].

It has long been assumed that very few patients embarking on medical GR regret their choice and seek to reverse it. From the 1970s to the 2010s, estimates of those regretting their initiated GR were only in the region of 2% [ 5 , 6 ]. However, more recent research suggests that alongside the increase in the number of people accessing medical gender reassignment, reversing the initiated transition seems to be increasing [ 7 ]. In recent samples, 20–30% of those who initiated hormonal GR discontinued hormonal treatment in four to five years [ 8 , 9 ]. It is possible that some patients discontinue hormonal treatment because they have reached their transition goals. Some changes, such as lowering of the voice, can be reached with relatively short hormonal treatments and are permanent, while maintaining some other changes require permanent treatment.

People abandoning their gender transition have reported various reasons for doing so, such as coming to terms with their natal sex, concerns about medical complications, attributing gender dysphoria to reasons other than gender identity, such as trauma or mental disorders, finding that the transition did not alleviate distress, struggles with sexual orientation and discrimination [ 10 , 11 ]. More importantly, those who have detransitioned have repeatedly reported that before their embarking on medical GR, insufficient attention was given to their mental health and psychosocial problems, which, in retrospect, they believed played a major role in their desire to transition. They have expressed concerns that assessments for medical gender reassignment were too superficial, with no search for explanations for their distress beyond an assumed stable sex-discordant identity requiring transition. [ 10 , 11 ]. This contradicts calls to lower the threshold for medical gender reassignment [ 12 , 13 ]. Several recent national guidelines and recommendations [ 4 , 14 , 15 ], however, emphasize the appropriate treatment of psychiatric comorbidities and associated difficulties as well as a psychosocial intervention facilitating identity exploration as first-line interventions for gender dysphoria before considering medical interventions, particularly for young people.

In Finland, gender identity assessments potentially leading to medical GR interventions are conducted at two of the country’s five university hospitals. Services for legal adults (> 18 years) have been available since the early 1990s [ 16 ] and became available to minors in 2011 [ 17 ]. The national guidelines require minors presenting with feelings of gender dysphoria to first undergo psychosocial intervention to support identity exploration and to receive appropriate treatment for any severe mental disorders [ 14 ], after which they can proceed to the centralized GIS, where diagnostic assessments are carried out by specialized mental health teams. Both GISs have separate diagnostic teams for minors and for adults. Hormonal GR interventions are initiated at the same hospitals in gynecological outpatient clinics, and after stabilization, hormonal treatment is transferred to services in the patients’ places of residence. Genital surgeries with gender identity indication are nationally centralized to one university hospital and require recommendations from both nationally centralized diagnostic GIS units. Psychiatric treatment for any concomitant mental health condition is provided at the specialized secondary care or primary health care facility in the patient’s place of residence. Until 2022, diagnostic assessments at the nationally centralized GIS were also a prerequisite for registered sex change, but since 3 April 2023, legal adults have been granted legal GR on the basis solely of their own request. Medical GR remains nationally centralized and is available case-by-case after a comprehensive diagnostic assessment by a multidisciplinary mental health team, as outlined in the national guidelines [ 14 , 18 , 19 ].

An important ethical principle in all medicine is to not harm. A more severe or life-threatening condition may justify greater risks in its treatment. In medical gender reassignment, hormonal and surgical interventions are performed on physically healthy bodies. If the patient subsequently regrets the changes brought by the treatments, not to mention undesired side effects, this can be considered harmful. As in other Western countries, alongside the vastly increasing number of referrals to the GIS, increasing numbers of younger people with increasingly common psychiatric needs have initiated medical GR in Finland [ 2 ]. This may be followed by increasing numbers of people who later feel otherwise about their medical GR. On the other hand, the purpose of the nationally centralized and comprehensive assessment before medical GR is to ensure reasoned treatment decisions and satisfactory patient outcomes, avoiding possible regrets. This may counteract the risks related to the more complex presentations among those seeking medical GR. Those abandoning their gender transitions have repeatedly claimed that the distress accompanying their situation is not appropriately addressed [ 20 ]. It is crucial to take seriously the desire to reverse medical GR and to ascertain its likelihood and predictors to target medical GR safely and provide appropriate services for those opting out of treatment that has resulted in irreversible changes in a healthy pretreatment body. In the present study, we referred to national registry data to determine which patients are likely to discontinue hormonal GR. More specifically, we asked:

How commonly did people who proceeded to hormonal GR after assessment in the nationally centralized GIS from 1996 to 2019 discontinue their established hormonal GR?

What are the predictors of discontinuation in terms of age, age at admission to the GIS, direction of transition, surgical treatment, psychiatric treatment needs and cohort effects?

Has the risk of discontinuing hormonal GR changed over time?

Design and setting

A register-based follow-up study was conducted using information held in health care registers in Finland. These comprehensive and reliable national registers can be used to study large patient groups and collate information from different registers (on an individual level) via the unique personal identity code assigned to each permanent resident of Finland. Register data can be applied for research purposes from the Finnish Social and Health Data Permit Authority Findata and Statistics Finland. Data extraction, linkages and pseudonymization are carried out by these authorities, and researchers are allotted a special secure connection for pseudonymized data only. Analyses producing unduly precise information potentially enabling a person to be identified must be amended to ensure the anonymity of the persons included. The present study obtained ethical approval from the ethics committee of Tampere University Hospital (R20040R) and relevant permissions from Findata (THL/5188/14.02.00/2020) and Statistics Finland (TK/1016/07.03.00/2020). In accordance with Articles 6e and 9i and j of Regulation (EU) 2016/679 of the European Parliament and of the Council [ 21 ], no individual informed consent was needed.

A personal identity code is assigned at birth (or upon obtaining Finnish citizenship). This indicates sex (male or female). Legal sex change entails a new identity code. People are listed in the national registers according to their currently valid personal identity code. This code serves to retrieve data from various registers (including earlier data under the original identity code). Researchers cannot obtain information about identity code changes (changes in juridical sex). Researchers using the data never see the actual identity codes.

Data extraction

Subjects referred to either of the two nationally centralized GISs were identified from the hospital databases of Tampere and Helsinki University Hospitals. The first contact with a diagnostic team in either of the two GISs was recorded as the index date. The Finnish Social and Health Data Permit Authority Findata combined the lists from the two hospitals. A total of 3,665 individuals were identified as having contacted the nationally centralized gender identity units between 1996 and 2019. Of these, 1,359 had initialized and embarked on feminizing or masculinizing hormonal treatment (see below, next paragraph) and formed the subjects of the present study.

The register of the Social Insurance Institution of Finland (KELA), with information on prescription medications purchased and information on reimbursement, was used to obtain information on hormonal GR in the clinical GD group. Persons diagnosed with F64.0 (since 2020, also F64.8) in the nationally centralized gender identity units are entitled to special reimbursement (code 121) for their hormonal treatment, as are patients suffering from specified endocrine disorders. In the treatment of gender dysphoria, special reimbursement is available when hormonal treatment has continued for more than a year. The data on prescription medications were collected up to the end of 2021.

The Care Register for Health Care [ 22 ] was used for information on all treatment contacts to specialist-level psychiatric services from 1994 to 2022. The register, which has been in operation since 1994, includes all outpatient and inpatient contacts with specialist-level health services in Finland. For all contacts, admission and discharge dates were extracted. The Care Register for Health Care was further used to provide information on gender reassignment surgeries.

The Population Register provided information on those deceased and their dates of death.

Discontinuing hormonal GR

Subjects entitled to special reimbursement for hormonal treatments were considered to have discontinued their hormonal GR if they had purchased no hormones for more than 12 months before the end of the data collection or, if deceased, for 12 months or more before their death, or if they had been purchasing specially reimbursed feminizing hormones but had later switched to masculinizing hormones, or vice versa. To obtain reimbursements for prescription medications from the Social Insurance Institution of Finland (KELA), these medications can be purchased for only three months at a time. Thus, not purchasing them for over a year means that they are most likely not being taken. The last date of purchase of the originally prescribed hormonal GR medication was recorded. Patients who discontinue hormonal GR may require birth-sex accordant hormonal replacement to detransition after gonad removal or if their natural hormone production does not resume. For subjects whose specially reimbursed hormone treatment had changed from masculinizing to feminizing or vice versa, the last date of purchase of the originally initiated type of hormonal GR was recorded.

Types and durations of hormonal GR

In the analyses, hormonal GR was divided into feminizing and masculinizing. The duration of hormonal GR with special reimbursement was calculated in months from the dates of first and last/latest purchase of the originally initiated masculinizing/feminizing hormones.

Time variables

The subject’s year of birth was used in the analyses as a continuous variable. The year of initial contact with the GIS (index year) was categorized into intake cohorts with the first contact with the GIS in 1996–2005 vs. 2006–2012 vs. 2013‒2019. As the inclusion period did not fall into three even periods, the first period, with a clearly lower case load, was extended.

Age at first contact with the GIS (index date) was calculated from the dates of index contact and birth. Age in years was used in bivariate analyses as a continuous variable. In multivariable analyses, age was divided into adolescent (up to 22 years old) and adult (23+) at index contact.

Gender reassignment surgeries

The gender reassignment surgeries recorded were genital surgery (vaginoplasty, phalloplasty/metoidioplasty) and chest masculinization.

Specialist-level psychiatric treatment contact

Specialist-level psychiatric treatment contacts other than those related to gender identity assessment were recorded. Having received specialist-level psychiatric treatment was used in the analyses as a comprehensive dichotomous variable (yes/no). Furthermore, having specialist-level psychiatric treatment contact before entering the GIS (yes/no) was used, as was having specialist-level psychiatric treatment two or more years after entering the GIS (yes/no).

Statistical analyses.

Bivariate associations between discontinuing hormonal GR and the explanatory variables were studied via cross-tabulations with chi-square statistics (Fisher’s exact test where appropriate) and the Mantel‒Haenszel test for categorical variables and t tests and ANOVA for continuous variables. Multivariate associations were studied via Cox regression, accounting for differences in follow-up times. Discontinuing hormonal GR was entered as the dependent variable. The independent variables entered were (1) direction of hormonal treatment (masculinizing/feminizing), year of birth and index year cohort; (2) GR surgeries; (3) age at first entering the GIS (adolescent vs. adult); and (4) and, finally, having received specialist-level psychiatric treatment (yes/no). Hazard ratios (HRs) with 95% confidence intervals are given. The cut-off for statistical significance was considered p  < 0.05.

There were 1,359 people who, after having been assessed in the nationally centralized GIS, had purchased masculinizing or feminizing hormones with a special reimbursement code. The mean (sd) age of the participants on admission to the GIS was 25.6 (9.3) years, and 49.1% of them were under 23 years of age. In total, 467 (34.4%) had received feminizing treatment, and 892 (65.6%) had received masculinizing treatment. At index contact with the GIS, those who subsequently initiated feminizing GR were older than those who proceeded to masculinizing GR (29.7 (11.1) vs. 23.4 (7.3) years, p  < 0.001). The mean (sd) duration of hormonal GR was 62.0 (57.0) months, with a median of 44.5 months, with no difference between masculinizing and feminizing treatments. Genital surgeries were more commonly performed on those who had proceeded to feminizing treatment (46.7% vs. 14.9%, p  < 0.001). Among those on masculinizing treatment, 41.5% had undergone chest masculinization. Among all patients proceeding to hormonal GR, 57.4% had ever had treatment contact with specialist-level psychiatric care.

A total of 107 subjects (7.9% of those who had started hormonal GR and obtained special reimbursement for it) had not been purchasing GR hormones for at least a year before the end of data collection (or before the subject died) or had changed from feminizing GR to masculinizing treatment, or vice versa. These were considered to have discontinued hormonal GR. Among those who had obtained feminizing GR, 10.5% had discontinued hormonal treatment, and among those who had obtained masculinizing GR, 6.5% ( p  = 0.004). Those who discontinued hormonal GR were slightly older at the index contact and at their latest purchase of specially reimbursed hormones than those who continued hormonal GR. The two groups had used hormonal GR for comparable periods. Those who discontinued and those who stayed on hormonal GR had comparable specialist-level psychiatric treatment contacts. (Table  1 )

Those who discontinued and those who continued hormonal GR had equally common specialist-level psychiatric treatment contact before contacting the GIS (15.3% vs. 17.8%, p  = 0.5) as well as two or more years after entering the GIS (59.9% vs. 57.0%, p  = 0.2).

Changes across intake cohorts

The basic characteristics of the subjects changed across intake cohorts. The mean (sd) age among those who had contacted the GIS from 1996 to 2005 and subsequently proceeded to hormonal GR was 31.1 (7.9); from 2006 to 2012, it was 25.7 (9.3); from 2013 to 2019, it was 24.8 (9.2) years ( p  < 0.001); and the proportion of adolescents (< 23-year-olds) was 13.7% vs. 48.9% vs. 53.6% ( p  < 0.001). The proportion of those seeking change towards masculinity increased, and the same change was observed among those discontinuing hormonal GR. The proportion of those with specialist-level psychiatric treatment contacts fluctuated between cohorts among those continuing hormonal GR but remained unchanged among those who discontinued it (Table  1 ).

Multivariable analyses

The hazard ratio (HR) for discontinuing hormonal GR was greater among those in the latest intake cohort (2013–2019) as compared to those in the earliest cohort (1996–2005) when the type of hormonal GR (masculinizing vs. feminizing) and year of birth were accounted for (Table  2 Model 1) and when surgical GR (Table  2 Model 2), age at index admission (adolescent vs. adult) (Table  2 Model 3) and, finally, specialist-level psychiatric treatment contact (Table  2 Model 4) were added. Genital surgeries were associated with a decreased HR for the discontinuation of hormonal GR. Earlier year of birth was very slightly but statistically significantly associated with increased HR for discontinuing hormonal GR in the first models but levelled out in subsequent models.

Confirmatory analyses

Because the oldest individuals in the sample may have discontinued hormonal GR due to reaching the age of natural decline in hormonal levels, the final model was repeated among individuals younger than 60 at the end of data collection, but this did not change the findings.

A further confirmatory analysis was carried out using data from those subjects whose index contact was before 2018 because of the rather short follow-up times among those who had started their gender identity assessments in 2018 or 2019. This caused no changes to the findings presented in Table  2 .

Changes in the discontinuation of hormonal GR over time

Survival curves for the three index date cohorts suggested that the discontinuation of hormonal GR emerged in a shorter time from the earliest to the latest intake cohort (Fig.  1 ). To explore this further, discontinuation within two years of obtaining special reimbursement for hormonal GR was scrutinized among those with index dates before 2018. Among the two earlier intake cohorts (combined due to small cell frequencies in the original categories), 1.3% of those who had started hormonal GR discontinued it within two years; among the latest intake cohort, 2.9% ( p  = 0.06).

Time (in years)* to discontinuing hormonal gender reassignment in the different intake cohorts (1 = 1996–2005, 2 = 2006–2012, 3 = 2013–2019). *modeled by Cox regression

In this nationally representative register study covering subjects proceeding to hormonal GR over three decades, 7.9% discontinued their established hormonal GR. The risk for discontinuing hormonal GR was greater in the latest intake cohort (2013–2019) than in the earliest cohort (1996–2005). Genital surgeries were associated with a decreased risk of discontinuing hormonal GR. Over the decades, the time to discontinuation grew shorter.

The proportion of those who discontinued treatment was smaller than that reported in the most comparable study [ 9 ] from the USA, where almost one-third of adolescents and young adults discontinued their hormonal GR within four years. The relatively low discontinuation rate in our study may be due to the comprehensive assessment in the nationally centralized GIS before initiating hormonal treatments. When severe psychiatric comorbidities are present, great care is taken in considering physical interventions [ 2 , 14 , 17 ]. The proportion of those who discontinued their established hormonal GR was nevertheless manifold compared with earlier reports of proportions regretting medical transition among samples who had initiated their treatments between the 1960s and 2010s [ 5 , 6 ]. However, both of those reports focused on actively expressed regrets, and in the latter study [ 6 ], the proportion lost to follow-up—with later development thus unknown—was high. The proportion discontinuing their established hormonal GR in the present study was comparable to the proportion defined as detransitioners (those who discontinued treatment and reverted to living in their original gender role) in a register-based study of 175 subjects initially assessed in 2017–18 in the UK [ 7 ]. However, in that UK study, a clearly greater additional share of the studied group also subsequently disengaged from the treatments or did not adhere to their treatment plan. In a study evaluating the situation of people diagnosed with GD in a specified GP practice population [ 8 ] and, as noted, in a register study in the USA [ 9 ], much greater shares discontinued their medical GR. Direct comparisons among these studies are not feasible because of their different focuses and methodologies. However, together with the most recent studies, our study suggests that discontinuing hormonal GR is a significant phenomenon in gender medicine, and studies reporting the experiences of detransitioners [ 10 , 11 ] suggest that it is often related to profound psychological distress.

In multivariate models accounting for differences in follow-up times and for changes in patient characteristics across intake cohorts, the risk of discontinuing hormonal GR was almost threefold among those patients who had contacted the GIS from 2013 to 2019 compared with those who had contacted the GIS from 1996 to 2005. Our findings also suggest that the time to discontinuation of hormonal GR may have shortened among the later patients; however, in the latest intake cohort, more discontinuations may still emerge, and this will eventually affect the final conclusions about the average time to discontinuation. The proportion of subjects who discontinued after short use, a maximum of two years of specially reimbursed medication use, nevertheless appeared to have increased. (This will mean a maximum of three years of total use, given the rules on special reimbursement). Over the whole study period, the number of people seeking GR increased manifoldly [ 2 ], as did the number of subjects proceeding to hormonal GR. Alongside with this, the risk of discontinuing established medical GR has also increased. The populations seeking medical GR may have changed in a way that limits positive treatment outcomes. It is already known that subjects currently seeking medical GR are, unlike earlier, predominantly birth-registered females, who are younger than before and present with more psychiatric comorbidities than before [ 1 , 2 , 3 , 20 ]. These observations may suggest that an increasing share of GD patients actually do not present with achieved, consolidated identity [ 20 , 23 ]. In particular, medical transition early in terms of identity development may increase the risk of unbalanced treatment decisions, and this risk appears to have increased towards the present day, with detransitioning as the next step. Greater attention to gender identity issues and GR in the media and social media as well as assertive advocacy for medical GR may play a role in these developments [ 20 , 24 , 25 ].

Somewhat unexpectedly, the need for specialist-level psychiatric care did not differentiate those who continued and those who discontinued hormonal GR. Approximately one in six of the patients who had started hormonal GR, both those who later discontinued and those who continued the treatment, had needed specialist-level psychiatric treatment before embarking on gender identity assessments. This number was clearly less than that of all patients who were in contact with the GIS [ 2 ]. It is expected that the two groups would be comparable at the time of the decision to initiate medical GR and suffer fewer psychiatric comorbidities than those who could not start medical GR. However, psychiatric treatment needs increased vastly after the index contact with the GIS in both groups who proceeded to medical GR, those who subsequently discontinued it and those who continued on hormonal GR. A more detailed analysis of the nature of psychiatric needs and subsequent identity struggles is needed to better understand the discontinuation of medical GR in the future. According to the multivariable analyses, the risk for discontinuing hormonal GR did not differ between those who had initially contacted the GIS during adolescence (< 23 years) and those who had contacted in adulthood. This may be due to assessments being particularly cautious with younger patients, whereas with middle-aged subjects, self-determination may be accorded greater significance.

Having undergone genital surgeries was predictive of a decreased risk of discontinuing hormonal treatments. This may be due to strict treatment protocols requiring psychological stability as part of eligibility for genital surgeries. A recommendation letter is required from both the nationally centralized GIS for gender surgeries to ensure both the patient’s capacity to consent and that their psychological and psychosocial resources will suffice to recover from major surgery.

Methodological considerations.

A strength of the present study is the use of nationwide registry data over three decades. The registers are comprehensive since treatment providers are required by law to report to them all the information on which this study relies. The subjects were identified in the databases of the hospitals where the nationally centralized GISs operate, thereby ensuring the reliability of sampling. The long inclusion period made it possible to analyse changes over time. A limitation is that only subjects who had obtained the special reimbursement code for their hormonal GR were included. There may be subjects who discontinued hormonal GR before their entitlement to special reimbursement (which can take place after a year), and their number is not known. Another limitation is that registers include no information on the reasons for discontinuing hormonal GR. Given the ample publicly funded health services and the special reimbursement for hormonal GR, financial problems are an unlikely reason. Further changes in identity, medical complications or concerns over them, not being helped by GR or social reasons, may contribute [ 10 , 11 , 20 ]. It is also possible that some achieved their goals and therefore discontinued, although this seems implausible in the case of discontinuation after many years. A more profound understanding of the reasons for discontinuing medical GR will require studies using information elicited directly from patients. A further limitation is that regarding the need for psychiatric treatment, this research focused on specialist-level service contacts reflecting severe psychiatric needs. Mild to moderate mental disorders are treated in primary health care. Thus, the need for psychiatric treatment was likely somewhat underestimated in the present study. A limitation is that the possible use of hormonal GR through unofficial routes was not addressed. Publicly funded medical GR interventions are possible only through nationally centralized gender identity services. Obtaining hormonal GR via unofficial routes would likely be related to medical GR not being considered timely in the official treatment route. This finding may suggest that the discontinuation of hormonal GR can be more common among those who obtain hormones unofficially. We combined minors (< 18 at intake to the GIS) and late adolescents (18–22-year-olds at intake) because before 2011, minors entered the assessments only occasionally. Brain development, personality development and identity consolidation continue well beyond the age of reaching legal adulthood [ 23 , 26 , 27 , 28 , 29 , 30 ]. Finally, discontinuing hormonal GR, desisting from identifying in a sex-discordant way, detransitioning and regretting medical GR are concepts referring partly to the same phenomenon but not totally overlapping [ 20 ]. A register-based study cannot reach these nuances.

Discontinuing established medical GR appears to be less common in Finland than reported elsewhere. This is likely due to careful, comprehensive assessment before initiating physical treatments. The risk of discontinuing established medical GR has nevertheless increased alongside increases in the number of patients seeking and proceeding to medical GR. In later intake cohorts, discontinuation also appears to emerge earlier. The threshold to initiate medical GR may have decreased, resulting in greater risks of suboptimal decisions. More research is needed on practically all aspects of detransitioning from medical GR.

Data availability

The authors are not allowed to give the data to any party. Information about how to apply Finnish register data for research purposes can be found in www.findata.fi.

Abbreviations

• Gender dysphoria

Gender identity service

Hazard ratio

Confidence interval

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RK, MH, TH and KT all contributed substantially to the design of the work; TH and RK curated the data; RK performed the analyses; MH consulted in statistical analyses; RK, MH, TH and KT interpreted the results; RK had the main responsibility of drafting the manuscript; MH, TH and KT participated in drafting the manuscript and approved the version submitted. All the authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All the authors reviewed and approved the manuscript.

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Kaltiala, R., Helminen, M., Holttinen, T. et al. Discontinuing hormonal gender reassignment: a nationwide register study. BMC Psychiatry 24 , 566 (2024). https://doi.org/10.1186/s12888-024-06005-6

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Supporting and understanding non-binary & gender diverse youth: a physician’s view

• Jamie Agapoff   ORCID: orcid.org/0000-0002-6026-6463 1  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  105 ( 2024 ) Cite this article

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Non-binary is a gender identity term describing a person whose gender exists between or outside the gender binary. Non-binary is also an umbrella term encompassing other gender identities such as genderqueer, genderfluid, agender, demigirl, demiboy, bigender, and others. As non-binary persons identify with a gender other than the one assigned at birth, they may be classified as transgender, although some may not identify with that label [ 1 ].

Population estimates of transgender and gender diverse (TGD) youth are varied [ 2 , 3 , 4 ]. Among youth ages 13 to 17 in the U.S., about 1.4% (~ 300,000) identify as transgender [ 3 ], and 1 in 4 identify as non-binary [ 4 ]. According to survey-based studies of children and adolescents, about 1.2–2.7% identify as transgender and 2.5–8.4% as TGD [ 2 ].

Despite a growing number of studies on transgender topics, a majority of this research still comes from the U.S. and Western Europe [ 2 , 5 ]. This special issue includes studies from South America [ 6 ] and the Middle East [ 7 ] where there are a paucity of studies. International data is helpful for expanding global applicability of treatment guidelines such as the Standards of Care released by the World Professional Association for Transgender Health [ 2 ].

Studies from this collection show transgender and gender diverse (TGD) youth face significant minority stressors and mental health concerns [ 8 , 9 , 10 ]. For example, Haywood et al., found that many TDG youth still face high levels of non-acceptance and bullying even after social transition [ 8 ]. Another study found that the experience of trans hostility is associated with an increase in gender dysphoria and poor peer relations in TGD youth [ 9 ]. And, in a systematic review, TGD adolescents with gender dysphoria experienced a high co-occurrence of psychosocial and psychological vulnerability, leading to greater risk for suicidal ideation and life-threatening behaviors [ 10 ].

Previous research demonstrates that mental health symptoms and gender dysphoria improve with access to gender affirmative care including social, surgical and hormonal interventions [ 11 , 12 , 13 , 14 , 15 , 16 ]. In one study of nonbinary and gender diverse youth, use of puberty blockers and gender-affirming hormones were associated with 73% lower odds of suicidality and 60% lower odds of moderate to severe depression [ 13 ]. Importantly, access to gender-affirming hormones during adolescence has been found to improve mental health outcomes in adulthood [ 14 ]. And, surgical interventions such as chest reconstruction have been shown to improve dysphoria and body satisfaction in gender diverse youth [ 12 , 16 ].

Yet, gender affirming care for youth is under attack. Legislative efforts to restrict access to gender affirming care are rampant, coordinated, and pervasive. Within the U.S. alone, nearly 39% of transgender youth live in states where there are bans on gender affirming care [ 17 ]. In the United Kingdom, life-saving treatments such as puberty blockers have been banned [ 18 ].

While credible scientific evidence about the positive benefits of gender affirming treatments struggle to find wide public dissemination [ 11 , 12 , 13 , 14 , 15 , 16 ], biased and methodologically flawed reports like the Cass Review are elevated within the public domain [ 19 , 20 ]. Providers should understand, practice, and disseminate best practice guidance for the care of TGD youth as outlined by the American Endocrine Society [ 21 ] and the World Professional Association for Transgender Health [ 2 ].

Providers who care for TGD youth should strive to adopt inclusive models that value self-determination and an affirmative approach [ 22 ]. Defensive models of care that focus on fringe concerns such as transition regret and mitigatable side effects are not supported by international treatment guidelines [ 2 ]. Similarly, intrusive and/or prolonged assessments that interrogate a youth’s gender identity and delay social or medical transitions are more likely to cause harm than good [ 23 ]. Providers should strive to support transgender youth at all stages of their social, medical, and legal transitions, while empowering and supporting them toward authentic gender identity and expression.

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Agapoff, J. Supporting and understanding non-binary & gender diverse youth: a physician’s view. Child Adolesc Psychiatry Ment Health 18 , 105 (2024). https://doi.org/10.1186/s13034-024-00798-w

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China man awaiting sex reassignment surgery sues hospital over forced electroshock therapy

• Live-streamer who posts videos wearing make-up and women’s clothing says he only went to hospital to keep parents happy

A man in China who is awaiting gender reassignment surgery has sued a hospital for 80,000 yuan (US$11,000) claiming he was forced to undergo electroshock therapy.

Linger, 27, is a live-streamer from Hebei province in northern China, who posts videos of himself online wearing make-up and women’s clothing.

He told Hongxing News that, although his biological sex is male, he has preferred the company of girls since childhood and, upon starting university, realised he identified as a woman.

Linger began taking oestrogen, one of the main female sex hormones. His facial hair became sparse, his voice softened, and he grew his hair long.

He has been saving money he made from live-streaming for years, hoping to undergo gender reassignment surgery.

Studies show that around four million people in China identify as transgender.

However, changing gender on official documents such as identity cards is only permitted after undergoing reassignment surgery.

The country’s strict standards require parental consent, and the procedure costs at least 150,000 yuan (US$21,000).

But Linger’s parents could not accept their son’s transition, which led to many arguments.

Traditional Chinese beliefs hold that the body is a gift from one’s parents and that gender is innate and should not be changed. Otherwise, it is considered disrespectful to parents.

Linger told Hongxing News that, to avoid further family conflict, he agreed to go to Jiulongshan Hospital in 2022 at his parents’ request.

He knew it was a psychiatric hospital, but he did not think he had a mental illness.

However, he did not expect the doctor to diagnose him with an “anxiety disorder” and “ego-dystonic sexual orientation”, which is a mental disorder that describes a conflict between a person’s desired and actual sexual orientation.

He was then stripped of his phone by medical staff and forcibly hospitalised for 97 days, according to Hongxing News.

“After being admitted to the hospital, I was tied to the bed with ropes, and many doctors controlled my body and administered electroshock therapy for days,” Linger said.

This year, Linger filed a lawsuit against the hospital for human rights violations, seeking 80,000 yuan in compensation.

On August 13, the hospital stated during the trial that they had “done nothing wrong”.

They argued that the purpose of electroshock was to control the emotions of psychiatric patients and enhance their self-awareness.

In China, being transgender is not classified as a mental illness.

Pan Bailin, a plastic surgeon in Beijing, said that using electroconvulsive therapy to try and reverse gender identity was not scientific.

“Transgender people are not mentally ill. They can alleviate their gender anxiety through psychological counselling, hormone therapy and voice training,” Pan said.

The hospital claimed that Linger’s mother had signed a consent form.

Chinese law allows for the involuntary hospitalisation of patients with mental disorders in specific cases, such as when they have shown, or are at risk of, self-harm or endangering others.

Legal experts contend that if these criteria are unmet, forced hospitalisation is unjustified.

Linger’s case is still being heard in court.

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There are loads of lakes around Tula, loads of forests and nice nature but not beach as such, i mean there is no sea beach, but some of the lakes and rivers are beautiful over there. Have a good time.

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Court rules on law requiring gender reassignment to change birth certificate

Howard Fischer, Capitol Media Services // August 22, 2024 // [read_meter]

(Deposit Photos)

Arizona can’t refuse to amend the sex on someone’s birth certificate just because the person seeking the change has not submitted to transgender surgery, a federal judge has ruled.

In an extensive decision, U.S. District Court Judge James Soto, an appointee of the former President Barack Obama, rejected arguments by the state Department of Health Services that allowing such changes would undermine the reason the state issues such documents: to provide a vital record of births, including the sex of the newborn. He said the state would still have the original record, though it would be sealed from outside scrutiny.

And Soto dismissed the claim that the records would have less meaning. He pointed out the health department already changes birth certificates when someone produces documentation from a physician of sex-change surgery.

And the judge questioned the different treatment provided by the state based solely on whether someone undergoes sexual reassignment surgery.

He said the evidence is that not everyone who does not identify with the gender of their birth needs surgery to live their lives.

Yet Soto said state law presents transgender individuals who want an amended birth certificate with a choice: Undergo surgery which may not be medically necessary or have to live with, and present when required, a birth certificate that does not reflect their gender. And that latter option, said the judge, forces those individuals to essentially “out” themselves as transgender, something he said violates their rights.

What Soto now needs to decide is what is an appropriate legal remedy. Attorney Rachel Berg of the National Center for Lesbian Rights, who is representing several individuals who filed suit, said that includes what evidence that a transgender individual who has not had surgery would have to present to the health department to get that amended birth certificate.

There was no immediate response from the Arizona Department of Health Services.

Less clear is the effect that the new ruling will have on another legal fight playing out in a different federal courtroom: Whether the state can refuse to allow transgender girls who were born male to participate in interscholastic or intramural sports.

The 2022 law says that all sports have to be labeled for males, females or coed. More to the point, it says that any team or sport designated as female “may not be open to the students of the male sex.”

Berg, who also is representing several prepubescent transgender girls in that case, said she does not believe that Soto’s ruling allowing them to get an amended birth certificate, by itself, will make any difference in that case. She said the definitions in that state law would still bar them from participating. 

But state schools chief Tom Horne told Capitol Media Service s he sees Soto’s ruling as undermining his defense of that 2022 law.

“They’re going to ruin women’s sports with all these guys having the natural advantage of being a male,” he said. “And then it’s a problem in the schools with bathrooms, showers and locker rooms.”

At the heart of the new ruling is gender dysphoria, a condition where a person’s gender identity does not match the sex assigned at birth, the one of an individual’s birth certificate.

Berg told the court that one of the treatments is to align the person’s life with his or her gender identity. And while that could include hormone-replacement therapy and surgery, it also starts with things like changing their names, using different pronouns, adopting clothing and grooming habits associated with their peers of the same gender identity.

Soto agreed.

“Not every transgender person needs surgery to complete a gender transition,” he wrote. “Starting social transitioning and other recommended therapy may eliminate the need for any potential surgical intervention.”

That, the judge said, is what is happening in the case of the three individuals, all children, who sued.

But Soto said that, absent a birth certificate that reflects their gender, something the state won’t issue absent surgery, they cannot continue their social transition. And that, the challengers said, presents problems when they are in situations where they are required to present a birth certificate.

“Their outward physical appearance will not fit with the gender marker on their birth certificate,” the judge said of their concerns. “Thus, if these documents are presented to others, they would, of course, be forced to involuntarily out themselves as transgender.”

And that, he said, results in unequal treatment.

“For non-transgender individuals – the vast majority of whom have an accurate birth certificate – they are not presented with the unlawful choice of being stripped of their bodily autonomy or face discrimination, harassment, and potential violence,” Soto wrote.

And he said there are studies to support the contention of transgender challengers that those who have to present birth certificates that do not match their identity, such as in school registration, are subject to being harassed, discriminated against or assaulted.

Horne brushed aside that question of transgender individuals outing themselves by having to present a birth certificate, perhaps to enroll in school, that doesn’t match their gender identity. He said there are ways to deal with discrimination.

“In the schools, we have to teach kids to respect everybody and to treat people as individuals, regardless of things like gender orientation,” he said. Horne compared it to his opposition to “ethnic studies” and what he called “critical race theory” where he said the focus is on how people are different.

And he insisted it should not be a problem for someone, required to present a birth certificate, to explain to whoever is asking for that document that represents only the sex at birth and does not reflect on who they now are.

Soto, however, said none of that should be necessary.

“If transgender individuals are uniquely faced with the decision to either undergo surgery, or involuntarily disclose their transgender status by presenting an inaccurate birth certificate, their right to privacy is implicated under the current statutory and regulatory regime,” he wrote. “Facially, the statute targets transgender individuals with an impossible and unconstitutional decision to either give up their bodily autonomy or disclose highly intimate details when they present these documents.”

Horne was unconvinced.

“The birth certificate should not be a false document,” he said.

That, however, ignores the fact that Arizona already does allow for an amended birth certificate and sealing the original one. The issue here is whether that option should be available to those who choose not to have surgery.

State health officials had argued that the statute does provide a work-around: Individuals can go to court and seek an order directing the agency to issue an amended certificate.

But Soto said the record shows that state judges have also required some proof of surgery to issue their orders. And even if they did not, Soto said it still imposes a burden.

“Transgender individuals must sue the government, navigate the litigation process and hope the courts seal the documents to protect their privacy,” he said.

And what of bathrooms and locker rooms?

Republican lawmakers approved a measure in 2023 blocking transgender students from using facilities that do not match their biological sex, only to have it vetoed by Democratic Gov. Katie Hobbs. A similar bill this year limited only to locker rooms met a similar fate.

Berg said that, strictly speaking, none of this issue gets resolved based on a student having a birth certificate that reflects his or her gender identity.

But she said this new ruling about the rights of transgender individuals sets a precedent: Any successful effort in Arizona to pass laws with such a restriction would face “heightened scrutiny” if challenged, meaning a higher burden on anyone who is trying to defend it.

Soto also said there is precedent for his ruling about not needing to have surgery to adjust government records. He said the U.S. Department of State and the Social Security Administration allow applicants to change the gender on their identity documents without proof of surgery.

And the judge said that option also is available from the Arizona Department of Transportation on designation on a driver’s license. That allows a change in gender designation as long as there  is a statement by a licensed physician that the person is “irrevocably committed to the gender-change process.”

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Missouri now requires proof of surgery or court order for gender changes on IDs

State Rep. Justin Sparks, R-Wildwood, fields questions from reporters during a press conference to address a transgender woman using the women’s locker room at the Life Time fitness center in Ellisville, Mo., Friday, Aug. 2. (Ethan Colbert/St. Louis Post-Dispatch via AP)

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COLUMBIA, Mo. (AP) — Missouri residents now must provide proof of gender-affirmation surgery or a court order to update their gender on driver’s licenses following a Revenue Department policy change.

Previously, Missouri required doctor approval, but not surgery, to change the gender listed on state-issued identification.

Missouri’s Revenue Department on Monday did not comment on what prompted the change but explained the new rules in a statement provided to The Associated Press.

“Customers are required to provide either medical documentation that they have undergone gender reassignment surgery, or a court order declaring gender designation to obtain a driver license or nondriver ID card denoting gender other than their biological gender assigned at birth,” spokesperson Anne Marie Moy said in the statement.

LGBTQ+ rights advocacy group PROMO on Monday criticized the policy shift as having been done “secretly.”

“We demand Director Wayne Wallingford explain to the public why the sudden shift in a policy that has stood since at least 2016,” PROMO Executive Director Katy Erker-Lynch said in a statement. “When we’ve asked department representatives about why, they stated it was ‘following an incident.’”

According to PROMO, the Revenue Department adopted the previous policy in 2016 with input from transgender leaders in the state.

Some Republican state lawmakers had questioned the old policy on gender identifications following protests, and counterprotests, earlier this month over a transgender woman’s use of women’s changing rooms at a suburban St. Louis gym.

“I didn’t even know this form existed that you can (use to) change your gender, which frankly is physically impossible genetically,” Republican state Rep. Justin Sparks said in a video posted on Facebook earlier this month. “I have assurances from the Department of Revenue that they are going to immediately change their policy.”

Life Time gym spokesperson Natalie Bushaw previously said the woman showed staff a copy of her driver’s license, which identified her as female.

It is unclear if Missouri’s new policy would have prevented the former Life Time gym member from accessing women’s locker rooms at the fitness center. The woman previously told the St. Louis Post-Dispatch that she has had several gender-affirming surgeries.

Life Time revoked the woman’s membership after the protests, citing “publicly available statements from this former member impacting safety and security at the club.”

The former member declined to comment Monday to The Associated Press.

“This action was taken solely due to safety concerns,” spokesperson Dan DeBaun said in a statement. “Life Time will continue to operate our clubs in a safe and secure manner while also following the Missouri laws in place to protect the human rights of individuals.”

Missouri does not have laws dictating transgender people’s bathroom use. But Missouri is among at least 24 states that have adopted laws restricting or banning gender-affirming medical care for minors.

“Missouri continues to prove it is a state committed to fostering the erasure of transgender, gender expansive, and nonbinary Missourians,” Erker-Lynch said.

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