scholarly articles on gender reassignment surgery

ORIGINAL RESEARCH article

Male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

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

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

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

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

Introduction

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

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

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

Patients and Methods

Subjects and study setup.

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

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

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

Hormonal Therapy

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

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

Operative Technique

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

Figure 1 . The initial circumferential subcoronal incision.

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

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

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

Figure 5 . The inverted penile skin flap.

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

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

Postoperative Care and Follow-Up

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

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

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

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

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

Patient Demographics

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

Table 1 . Patient demographics.

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

Postoperative Results

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

Table 2 . Complications after penile inversion vaginoplasty.

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions

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

Data Availability Statement

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

Ethics Statement

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

Author Contributions

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

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

Conflict of Interest

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

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

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

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

Reviewed by:

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

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

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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

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

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This article has been updated

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

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

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

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

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

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

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

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Change history, 26 april 2011.

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

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

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

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

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

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

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National Estimates of Gender-Affirming Surgery in the US

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Accepted for Publication: July 15, 2023.

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

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

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

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

Concept and design: Wright, Chen.

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

Drafting of the manuscript: Wright.

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

Statistical analysis: Wright, Chen.

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

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

Data Sharing Statement: See Supplement 2 .

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Gender-affirming surgeries (GASs), previously known as gender reassignment surgeries, are surgical procedures born from plastic and reconstructive surgery, colorectal surgery, urology, and gynecology. A multidisciplinary approach is essential for the care of transgender patients. The urologist plays a vital role, both in the perioperative period and as part of continued care. This publication will review the current concepts of genital GAS as it pertains to the practicing urologist. The most utilized surgical techniques will be described along with their notable complications and management options.

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The Lawfulness of Gender Reassignment Surgery

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Penney Lewis, The Lawfulness of Gender Reassignment Surgery, American Journal of Legal History , Volume 58, Issue 1, March 2018, Pages 56–85, https://doi.org/10.1093/ajlh/njx032

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In the common law world, both the medical and legal professions initially considered gender reassignment surgery to be unlawful when first practised and discussed in the first half of the twentieth century. While most medical procedures are covered by the medical exception to the law governing serious offences against the person, many doctors and the lawyers they consulted doubted that this exception applied to gender reassignment surgery. In this article I trace the differing and changing interpretations of the medical exception as applied to gender reassignment surgery, and the shift towards legal acceptance in the two common law jurisdictions that led the way in both performing gender reassignment surgery and debating its legality, the United States and the United Kingdom. Although this shift occurred without formal legal intervention either through legislation or judicial decision (for example on a test case), inferences of legality drawn from related civil-law decisions bolstered the legal acceptance of gender reassignment surgery.

By increasing the suffering of patients and potential patients, the criminal law played both an important and primarily malign role prior to the eventual public, professional and legal acceptance of GRS. A real threat of criminal prosecution inhibited doctors from proceeding, distorted diagnoses and affected the kinds of procedures performed. After-care was expanded and manipulated to avoid the risk of prosecution or the appearance of unlawful surgery. By contrast, civil and administrative law played a more positive, albeit indirect, role in interpreting the medical exception and its application to gender reassignment surgery.

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May 12, 2022

What the Science on Gender-Affirming Care for Transgender Kids Really Shows

Laws that ban gender-affirming treatment ignore the wealth of research demonstrating its benefits for trans people’s health

By Heather Boerner

As attacks against transgender kids increase in the U.S., Minnesotans hold a rally at the state’s capitol in Saint Paul in March 2022 to support trans kids in Minnesota and Texas and around the country.

Michael Siluk/UCG/Universal Images Group via Getty Images

Editor’s Note (3/30/23): This article from May 2022 is being republished to highlight the ways that ongoing anti-trans legislation is harmful and unscientific.

For the first 40 years of their life, Texas resident Kelly Fleming spent a portion of most years in a deep depression. As an adult, Fleming—who uses they/them pronouns and who asked to use a pseudonym to protect their safety—would shave their face in the shower with the lights off so neither they nor their wife would have to confront the reality of their body.

What Fleming was experiencing, although they did not know it at the time, was gender dysphoria : the acute and chronic distress of living in a body that does not reflect one’s gender and the desire to have bodily characteristics of that gender. While in therapy, Fleming discovered research linking access to gender-affirming hormone therapy with reduced depression in transgender people. They started a very low dose of estradiol, and the depression episodes became shorter, less frequent and less intense. Now they look at their body with joy.

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So when Fleming sees what authorities in Texas , Alabama , Florida and other states are doing to bar transgender teens and children from receiving gender-affirming medical care, it infuriates them. And they are worried for their children, ages 12 and 14, both of whom are agender—a identity on the transgender spectrum that is neither masculine nor feminine.

“I’m just so excited to see them being able to present themselves in a way that makes them happy,” Fleming says. “They are living their best life regardless of what others think, and that’s a privilege that I did not get to have as a younger person.”

Laws Based on “Completely Wrong” Information

Currently more than a dozen state legislatures  or administrations are considering—or have already passed—laws banning health care for transgender young people. On April 20 the Florida Department of Health issued guidance to withhold such gender-affirming care. This includes social gender transitioning—acknowledging that a young person is trans, using their correct pronouns and name, and supporting their desire to live publicly as the gender of their experience rather than their sex assigned at birth. This comes nearly two months after Texas Governor Greg Abbott issued an order for the Texas Department of Family and Protective Services to investigate for child abuse parents who allow their transgender preteens and teenagers to receive medical care. Alabama recently passed SB 184 , which would make it a felony to provide gender-affirming medical care to transgender minors. In Alabama, a “minor” is defined as anyone 19 or younger.

If such laws go ahead, 58,200 teens in the U.S. could lose access to or never receive gender-affirming care, according to the Williams Institute at the University of California, Los Angeles. A decade of research shows such treatment reduces depression, suicidality and other devastating consequences of trans preteens and teens being forced to undergo puberty in the sex they were assigned at birth).

The bills are based on “information that’s completely wrong,” says Michelle Forcier, a pediatrician and professor of pediatrics at Brown University. Forcier literally helped write the book on how to provide evidence-based gender care to young people. She is also an assistant dean of admissions at the Warren Alpert Medical School of Brown University. Those laws “are absolutely, absolutely incorrect” about the science of gender-affirming care for young people, she says. “[Inaccurate information] is there to create drama. It’s there to make people take a side.”

The truth is that data from more than a dozen studies of more than 30,000 transgender and gender-diverse young people consistently show that access to gender-affirming care is associated with better mental health outcomes—and that lack of access to such care is associated with higher rates of suicidality, depression and self-harming behavior. (Gender diversity refers to the extent to which a person’s gendered behaviors, appearance and identities are culturally incongruent with the sex they were assigned at birth. Gender-diverse people can identify along the transgender spectrum, but not all do.) Major medical organizations, including the American Academy of Pediatrics (AAP) , the American Academy of Child and Adolescent Psychiatry , the Endocrine Society , the American Medical Association , the American Psychological Association and the American Psychiatric Association , have published policy statements and guidelines on how to provide age-appropriate gender-affirming care. All of those medical societies find such care to be evidence-based and medically necessary.

AAP and Endocrine Society guidelines call for developmentally appropriate care, and that means no puberty blockers or hormones until young people are already undergoing puberty for their sex assigned at birth. For one thing, “there are no hormonal differences among prepubertal children,” says Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City and co-author of the Endocrine Society’s guidelines. Those guidelines provide the option of gonadotropin-releasing hormone analogues (GnRHas), which block the release of sex hormones, once young people are already into the second of five puberty stages—marked by breast budding and pubic hair. These are offered only if a teen is not ready to make decisions about puberty. Access to gender-affirming hormones and potential access to gender-affirming surgery is available at age 16—and then, in the case of transmasculine youth, only mastectomy, also known as top surgery. The Endocrine Society does not recommend genital surgery for minors.

Before puberty, gender-affirming care is about supporting the process of gender development rather than directing children through a specific course of gender transition or maintenance of cisgender presentation, says Jason Rafferty, co-author of AAP’s policy statement on gender-affirming care and a pediatrician and psychiatrist at Hasbro Children’s Hospital in Rhode Island. “The current research suggests that, rather than predicting or preventing who a child might become, it’s better to value them for who they are now—even at a young age,” Rafferty says.

A Safe Environment to Explore Gender

A 2021 systematic review of 44 peer-reviewed studies found that parent connectedness, measured by a six-question scale asking about such things as how safe young people feel confiding in their guardians or how cared for they feel in the family, is associated with greater resilience among teens and young adults who are transgender or gender-diverse. Rafferty says he sees his role with regard to prepubertal children as offering a safe environment for the child to explore their gender and for parents to ask questions. “The gender-affirming approach is not some railroad of people to hormones and surgery,” Safer says. “It is talking and watching and being conservative.”

Only once children are older, and if the incongruence between the sex assigned to them at birth and their experienced gender has persisted, does discussion of medical transition occur. First a gender therapist has to diagnose the young person with gender dysphoria .

After a gender dysphoria diagnosis—and only if earlier conversations suggest that hormones are indicated—guidelines call for discussion of fertility, puberty suppression and hormones. Puberty-suppressing medications have been used for decades for cisgender children who start puberty early, but they are not meant to be used indefinitely. The Endocrine Society guidelines recommend a maximum of two years on GnRHa therapy to allow more time for children to form their gender identity before undergoing puberty for their sex assigned at birth, the effects of which are irreversible.

“[Puberty blockers] are part of the process of ‘do no harm,’” Forcier says, referencing a popular phrase that describes the Hippocratic Oath, which many physicians recite a version of before they begin to practice.

Hormone blocker treatment may have side effects. A 2015 longitudinal observational cohort study of 34 transgender young people found that, by the time the participants were 22 years old, trans women experienced a decrease in bone mineral density. A 2020 study of puberty suppression in gender-diverse and transgender young people found that those who started puberty blockers in early puberty had lower bone mineral density before the start of treatment than the public at large. This suggests, the authors wrote, that GnRHa use may not be the cause of low bone mineral density for these young people. Instead they found that lack of exercise was a primary factor in low bone-mineral density, especially among transgender girls.

Other side effects of GnRHa therapy include weight gain, hot flashes and mood swings. But studies have found that these side effects—and puberty delay itself—are reversible , Safer says.

Gender-affirming hormone therapy often involves taking an androgen blocker (a chemical that blocks the release of testosterone and other androgenic hormones) and estrogen in transfeminine teens, and testosterone supplementation in transmasculine teens. Such hormones may be associated with some physiological changes for adult transgender people. For instance, transfeminine people taking estrogen see their so-called “good” cholesterol increase. By contrast, transmasculine people taking testosterone see their good cholesterol decrease. Some studies have hinted at effects on bone mineral density, but these are complicated and also depend on personal, family history, exercise, and many other factors in addition to hormones.”

And while some critics point to decade-old study and older studies suggesting very few young people persist in transgender identity into late adolescence and adulthood, Forcier says the data are “misleading and not accurate.” A recent review detailed methodological problems with some of these studies . New research in 17,151 people who had ever socially transitioned found that 86.9 percent persisted in their gender identity. Of the 2,242 people who reported that they reverted to living as the gender associated with the sex they were assigned at birth, just 15.9 percent said they did so because of internal factors such as questioning their experienced gender but also because of fear, mental health issues and suicide attempts. The rest reported the cause was social, economic and familial stigma and discrimination. A third reported that they ceased living openly as a trans person because doing so was “just too hard for me.”

The Harms of Denying Care

Data suggest the effects of denying that care are worse than whatever side effects result from delaying sex-assigned-at-birth puberty. And medical society guidelines conclude that the benefits of gender-affirming care outweigh the risks. Without gender-affirming hormone therapy, cisgender hormones take over, forcing body changes that can be permanent and distressing.

A 2020 study of 300 gender-incongruent young people found that mental distress—including self-harm, suicidal thoughts and depression— increased as the children were made to proceed with puberty according to their assigned sex. By the time 184 older teens (with a median age of 16) reached the stage in which transgender boys began their periods and grew breasts and transgender girls’ voice dropped and facial hair began to appear, 46 percent had been diagnosed with depression, 40 percent had self-harmed, 52 percent had considered suicide, and 17 percent had attempted it—rates significantly higher than those of gender-incongruent children who were a median of 13.9 years old or of cisgender kids their own age.

Conversely, access to gender-affirming hormones in adolescence appears to have a protective effect. In one study, researchers followed 104 teens and young adults for a year and asked them about their depression, anxiety and suicidality at the time they started receiving hormones or puberty blockers and again at the three-month, six-month and one-year mark. At the beginning of the study, which was published in JAMA Network Open in February 2022, more than half of the respondents reported moderate to severe depression, half reported moderate to severe anxiety, and 43.3 percent reported thoughts of self-harm or suicide in the past two weeks.

But when the researchers analyzed the results based on the kind of gender-affirming care the teens had received, they found that those who had access to puberty blockers or gender-affirming hormones were 60 percent less likely to experience moderate to severe depression. And those with access to the medical treatments were 73 percent less likely to contemplate self-harm or suicide.

“Delays in prescribing puberty blockers and hormones may in fact worsen mental health symptoms for trans youth,” says Diana Tordoff, an epidemiology graduate student at the University of Washington and co-author of the study.

That effect may be lifelong. A 2022 study of more than 21,000 transgender adults showed that just 41 percent of adults who wanted hormone therapy received it, and just 2.3 percent had access to it in adolescence. When researchers looked at rates of suicidal thinking over the past year in these same adults, they found that access to hormone therapy in early adolescence was associated with a 60 percent reduction in suicidality in the past year and that access in late adolescence was associated with a 50 percent reduction.

For Fleming’s kids in Texas, gender-affirming hormones are not currently part of the discussion; not all trans people desire hormones or surgery to feel affirmed in their gender. But Fleming is already looking at jobs in other states to protect their children’s access to such care, should they change their mind. “Getting your body closer to the gender [you] identify with—that is what helps the dysphoria,” Fleming says. “And not giving people the opportunity to do that, making it harder for them to do that, is what has made the suicide rate among transgender people so high. We just—trans people are just trying to survive.”

IF YOU NEED HELP If you or someone you know is struggling or having thoughts of suicide, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.

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Biden ‘gender reassignment’ surgery mandate blocked

By Peter Pinedo

Houston, Texas, Sep 3, 2024 / 16:45 pm

A U.S. district judge has placed a nationwide block on a Biden-Harris administration rule mandating that federally funded hospitals perform surgical interventions to alter the body’s appearance to mimic that of the opposite sex.

This comes after Texas and Montana sued the administration over changes it made in May to the Affordable Care Act’s section prohibiting discrimination based on sex.

The rule broadened the meaning of “sex” to include “gender identity.” This meant that federally funded hospitals were required to perform so-called “gender reassignment” surgeries or face a range of penalties including having their funding removed.

Texas and Montana argued that the change violated portions of state law that prohibit such surgical interventions performed on minors’ sexual and reproductive organs and ban Medicaid funding for these operations.

The two states argued that the Biden administration has given them “an impossible choice” to either “violate and abandon state law or risk devastating financial loss.”

The ruling, issued on Aug. 30 by Judge Jeremy Kernodle for the Eastern District of Texas, expanded an earlier court decision that blocked the mandate for hospitals in Texas and Montana. Kernodle said the Biden administration’s mandate is “unlawful” in all hospitals, not just those in Texas and Montana.

Texas Attorney General Ken Paxton called the ruling a “major victory for Americans across the country.”

“When Biden and Harris sidestep the Constitution to force their unlawful, extremist agenda on the American public, we are fighting back and stopping them,” Paxton said.

Jennifer Carr Allmon, executive director of the Texas Catholic Conference of Bishops, told CNA that the Texas bishops are “grateful” for the nationwide stay.  

Catholic experts respond to Pope Francis on repelling migrants being ‘a grave sin’

Allmon said that gender transition surgeries are “not authentic health care” because these procedures “interrupt natural developmental processes and can result in infertility and other serious health risks, especially for children, all of which may be irreversible.”

“Health care providers must be free to refuse to perform these harmful interventions without risk of penalty,” she said. “The Texas Catholic Conference of Bishops advocates for health care that is oriented toward honoring the dignity of each person while respecting the religious liberty and conscience rights of medical professionals.”

The Biden administration will likely appeal the ruling to the Fifth Circuit Appellate Court.

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Psychological Outcomes and Reproductive Issues Among Gender Dysphoric Individuals

Affiliations.

• 1 Department of Psychiatry, Yale University School of Medicine, 500 University Drive, Hershey, PA 17033, USA.
• 2 Pennsylvania State University College of Medicine, Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA. Electronic address: [email protected].
• PMID: 26568492
• DOI: 10.1016/j.ecl.2015.08.001

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

Keywords: Fertility; Gender dysphoria; Gender-affirmation therapy; Psychiatric comorbidities; Transgender.

Copyright © 2015 Elsevier Inc. All rights reserved.

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Transgender children and young people: how the evidence can point the way forward

Philip graham.

University College, London, UK

Associated Data

Data availability is not applicable to this article as no new data were created or analysed in this study.

The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.

Children first begin to develop a sense of biological gender at around the age of 2 to 3 years. 1 At this age, they are able to label pictures of boys and girls according to typical presentations of heteronormativity. At 4 years, boys understand that it is the possession of a penis that marks them out as biologically male and girls understand it is the lack of a penis that means they are biologically female. By this age, children have a sense of the stability of biological gender, an understanding that it remains constant with time. From this point up to the age of 6 or 7 years, their judgement of gender in pictures of clothed children is heavily influenced by appearance so that they label boys pictured in dresses as girls and boys with long hair as girls. By 7 years they recognise biological sex as constant and independent of external appearance. 1

By the age of 7 years, therefore, children understand three different concepts related to sex/gender identity: biological sex, self-perceived gender identity and social gender identity. They understand that they and others are biologically male or female, that they and others have a sense of their own gender identity as male or female and that they and others, depending on their appearance and clothing, are usually perceived by others as male or female. As they develop into adolescence and adulthood, people recognise that, with the use of hormones and surgical interventions, some features of biological sex can be changed. Both self-perceived gender identity and social gender identity may also undergo change.

The great majority of young children develop a self-perceived gender identity consonant with their gender assigned at birth, but some, from the age of 3 or 4 years, develop a self-perceived gender identity which is other than that assigned at birth. This sense of another gender identity can be accompanied by a feeling of discomfort or gender dysphoria. There are many autobiographical examples of the first awareness of gender dysphoria. The best known is that written by Jan Morris, who lived as a highly successful male journalist under the name of James Morris until her mid-30s when, following treatment with hormones, she underwent a surgical reconstruction and thereafter lived as a woman. 2 Jan Morris describes very clearly the onset of her gender dysphoria: 2 ‘I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1). Her sense of discomfort with her assigned gender at birth persisted throughout her childhood, adolescence and early adult life. She describes how, when in role as a young man, she used to pray ‘please God make me a girl’ (p. 39). Gender dysphoria persisted throughout her marriage and parenthood. It was only in her late 30s, after she had had gender reassignment surgery, that she felt at ease.

The majority of prepubertal girls and boys have a clear sense of their own gender identity as female or male. This is nearly always consistent with their gender assigned at birth; in some, like Jan Morris, it is not. In a study of adolescents who had been referred to a gender identity clinic in earlier childhood, Steensma et al were able to show that a high proportion of prepubertal children with gender dysphoria did not continue to show such dysphoria after puberty, 3 a finding that had previously been reported by the same group. 4 Further, children who had shown gender-atypical behaviour (see below) without intense gender dysphoria did not generally show gender dysphoria in adolescence. Those with gender dysphoria who had been assigned a female gender at birth were less likely to desist than those assigned a male gender. Those who persisted were much more likely to have a homosexual or bisexual orientation.

A sense of gender identity must be distinguished from the presence of gender-atypical behaviour, which may occur with or without gender dysphoria. Gender-atypical behaviour (boys behaving like girls and having interests generally regarded as feminine and vice versa ) is not uncommon in the general population. In a total population study, using a standardised instrument, Golombok et al were able to identify 112 boys and 113 girls aged 3.5 years who showed gender-atypical behaviour to an extreme degree. 5 This represented about 2.2% of the population studied (S. Golombok, personal communication, 5 Jan 2021). Especially for girls, there was considerable continuity between gender-atypical behaviours at 3.5 years and such behaviour at the age of 13 years. These investigators do not report whether any of the children in their study were referred for gender dysphoria. The prevalence of 2.2% for gender-atypical behaviour needs to be contrasted with the much less frequent prevalence of 1 per 6800 Dutch adolescents aged 12 to 18 years who requested medical help for gender dysphoria. 6

Gender dysphoria and the onset of sexual feelings

Between 9 and 13 years of age, children start to experience sexual feelings arising from their genitalia. This onset of sexual feelings coincides with biological changes known as gonadarche. At this point, as a result of changes in the hypothalamus and pituitary, the gonads begin to secrete the sex hormones, testosterone and oestradiol, in relatively small quantities. This results in a modest growth of hair around the pubes and in the armpits and growth of the penis and breasts respectively. Spontaneous penile erections and clitoral excitement occur. Around 2 years later, positive feedback occurs in the hypothalamo–pituitary–gonadal axis which stimulates the testes to produce much larger amounts of testosterone and the ovaries to secrete more oestradiol, leading to menstruation. These hormonal changes also result in much more intense experience of sexual desire.

In the majority of children, sexual attraction is heterosexual but around 10% of 16- to 44-year-old adults report some previous sexual contact with a member of the same sex. 7 Most of those who experience homosexual attraction are not transgender. Usually, they have not even shown gender-atypical behaviour; they have been typically masculine, if boys, and feminine, if girls. Transgender boys usually, but not always, feel attraction to others of the same natal sex, i.e. they have homosexual feelings, and transgender girls similarly feel attracted by others of the same natal sex. Inevitably, these sexual feelings are often associated with some degree of confusion and uncertainty. For most transgender boys and girls, however, homosexual feelings have the effect of confirming the child in their transgender role: ‘If I'm really a girl, it isn't surprising I'm attracted to boys’, a transgender natal boy might say to himself and vice versa for girls. But some transgender children develop sexual attraction for others of the opposite natal sex, again with the creation of confusion and uncertainty over the transgender role.

Adolescence and gender identity

Adolescence is a social construction, i.e. it is a phase of life defined by society. 8 In Western society, it is regarded as beginning at the onset of biological puberty. Its end is not, however, defined biologically, but usually by a social criterion such as the age at which the individual develops significant autonomy. In practice, most psychologists, clinicians and members of the general public equate adolescence with the teen years, from 13 to 19, although many young people are well into biological puberty by 13 years and will have completed the biological changes of puberty well before 19 years. Recently, Sawyer and colleagues in an influential article have argued for an expanded and more inclusive definition of adolescence corresponding with the longer period of transition from childhood to adulthood now experienced by young people in Western society. They suggest that the period of 10 to 24 years is more consistent with this experience. 9 It is of relevance that there is considerable variation in ages at onset and termination of biological puberty, some young people normally starting at 10 or 11 years old and others not completing puberty until their later teen years. Relatively recent neuroscientific studies have pointed to the fact that rapid biological changes occur in the brain during the teen years, 10 but these are by no means specific to this phase of life. 11

The general public regard various behaviours as characteristic of adolescence. These may be summarised as impulsiveness, a tendency to take risks, moodiness and fractious relationships with parents. The public image of adolescents accords with this view of ‘the typical adolescent’. It is certainly the case that some teenagers show these characteristics, but population studies suggest that they make up no more than about 10–15% of this age group, 12 although they are certainly the most conspicuous. Another important and, in the context of this article, the most relevant feature of adolescence is thought to be self-questioning about identity. Young people of this age are seen as preoccupied with the question ‘Who am I?’, a question relating to all aspects of their identities, including their gender and sexuality. Such self-questioning is not experienced in intense form by most teenagers. The prevalence of ‘identity problems’ was found to be 14.3% in a group of 15- to 18-year-old American high school students 13 and a similar prevalence of ‘identity distress’ was found in a study of Flemish adolescents and young people aged 14–30 years. 14 The considerable increase in exposure of teenagers in the past 10 to 15 years to social media replete with references to gender identity would make it surprising if there had not been at least some increase of such self-questioning and confusion in this area.

Teenage presentation of transgender

Clinics serving the adolescent transgender population observed a change in the referral pattern after about 2005. Most notably, the gender identity clinic in Toronto, Canada, reported a dramatic increase in referrals at that time. 15 At the Portman Clinic in London (part of the Tavistock and Portman NHS Trust) referrals increased very significantly from 2009 to 2016. 16 At the Tampere University Hospital, Finland, referrals between 2011 and 2013 far exceeded the number expected from the findings of epidemiological studies. 17 This had not been the case previously. There were two other changes in the referral pattern over this period. First, previously, roughly equal numbers of boys and girls had been referred, whereas the increase was associated with much higher numbers of those who had been assigned female gender at birth. Second, previously, the rates of mental ill health among referred children had been about the same as in the general population, 18 whereas now much higher rates of psychiatric disorder, including autism, were reported. 14 , 16

It is therefore clear that from 2005 in Toronto and a few years later in other centres, the characteristics of patients referred to transgender clinics in their early and mid-teen years changed very significantly. In considering the reasons for this new pattern, Aitken et al 15 suggest that one possibility is that, during this period, societal factors made it easier for gay and lesbian youth and their families to seek clinical care. It could be argued, those authors say, that it became easier for girls to ‘come out’ than boys. It might therefore be easier for girls to opt for a transgender identity. Although there is no evidence to this effect, transgender natal girls who found themselves attracted to girls at puberty might have also found it easier to come out as transgender than hitherto. This implies that the increased presentation at adolescence was of girls who had experienced gender dysphoria since their early years. There is another possibility. It is that girls in their teens who are showing mental health problems for other reasons might, searching for an answer to their identity problems or distress, be influenced by social media to question for the first time their gender identity and to see gender change as an answer to their mental dilemmas. This might be more likely if they had previously shown ‘tomboyish’ behaviour. This possibility has been suggested in considering reasons for an increase in referrals of natal girls to a gender identity service between 2009 and 2016. 15 However, both these possibilities remain hypothetical at present and the reasons for the increase in referrals to transgender clinics is unknown.

Although one should not draw conclusions from a single case, it is of interest that one of the claimants in a judicial review brought about because they felt they had been inappropriately treated with puberty blocking drugs gives an account of her transgender development very much in accord with this second possibility. The claimant described a highly traumatic childhood in which she showed many gender-atypical behaviours: ‘ From the age of 14 she began actively to question her gender identity and started to look at YouTube videos and do research on the internet about gender identity disorder and the transition process’ (para. 78). 19

Although some cases of first presentation of transgender in the early teen years may arise from so-called adolescent identity problems or identity distress, it is likely that others do occur because the young person has been reluctant to come out as transgender beforehand, even though gender dysphoria has been present from the early years. Further, it is well established that such reluctance may persist well into adulthood, so that there are a number of recorded cases of people who have waited until their 30s or 40s to make this decision. 20

There is a need for both quantitative and qualitative research to investigate the early histories of girls referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years.

Life for children who are transgender from their early years can be challenging. At home, they have to try to communicate how they feel to potentially sceptical parents. At school, they are likely to experience disbelief, mockery and bullying. To cope they need resilient personalities as well as sensitive and understanding parents who are able to explore and talk openly about their children's feelings with acceptance and without trying to influence decisions one way or another. For, as we have seen, although some prepubertal children persist in their transgender identity, in the course of time many will, for reasons we do not understand, desist. 3 It is remarkable that most children who have been transgender from a young age reach adolescence without developing a higher-than-expected rate of significant mental health problems. 17

Many prepubertal children and their parents will benefit from having available a sympathetic counsellor, psychotherapist or other mental health professional. This will allow exploration of the reasons for the presence of gender dysphoria. Material from voluntary organisations such as Mermaids may be helpful, but parents of young children need to monitor this to ensure that their children are not being encouraged to persist, but are just accepted for what they are at the present time. Difficult decisions about changes of name and the use of toilets need to be negotiated with hopefully sympathetic, open-minded teachers.

As puberty approaches, difficult decisions have to be made. The Amsterdam group has been offering transgender adolescents puberty blockers for 30 years, their first case having been treated in 1991. 21 The group has pioneered an approach to assessment and management of gender dysphoria. It has produced a protocol for medical treatment of transgender children and adolescents that has been widely followed, 22 for example in Italy, Canada, the USA and the UK. The protocol is summarised below and in Box 1 :

• Psychological counselling for children and parents starts well before any medical treatment is considered and continues while such intervention is being administered.
• Once Tanner stage 2–3 is reached, and not before, gonadotropin-releasing hormone analogues (GnRHa) are prescribed where there is a clear indication that this is the appropriate course. This medication is given to block pubertal changes, so that the bodily changes rejected by the young person do not occur. Such treatment is only offered to children and young people aged 12 years and older who have intense gender dysphoria and no significant mental health problems. Informed consent by the young person and by the parents is required. The purpose of the use of puberty blockers is to ensure that young people with gender dysphoria do not live through pubertal bodily changes they find abhorrent. Further, the blocking of pubertal changes means that when, as is nearly always the case, transgender adults choose to have at least some degree of gender reassignment surgery, some procedures, particularly bilateral mastectomy for those assigned female gender at birth, will not be necessary.
• With careful assessment and selection, a very small minority of young people prescribed puberty blockers (between 1.4 and 3.5%) change their minds and do not wish to proceed further. 23 For the large majority who do wish to proceed, around the age of 16 years or older, cross-sex hormones are prescribed. For this treatment to be started, the young person must be living in the role of the preferred gender. Again, informed consent by the young person and, preferably, the parents is required.
• At the age of 18 years or older, those (again the great majority) who meet eligibility criteria can begin the process of gender reassignment surgery. Such surgery occurs variably according to the degree and at the pace desired by the individual concerned.

Management of gender dysphoria 22

• Make a full assessment as early as possible
• Follow with supportive counselling throughout childhood and adolescence
• Subsequent interventions should only take place with informed consent, first by parents and then by the young person, with reflection before each phase
• If intense gender dysphoria persists, consider using puberty blockers at Tanner stages 2–3
• Consider use of cross-sex hormones at age 16
• At age 18–19 and subsequently, consider gender reassignment surgery

Effectiveness of treatment

The aims of treatment are twofold:

• to explore with the child or young person with gender dysphoria the reasons for their discomfort with their gender assigned at birth and to consider alternative ways forward, including living in the role of their birth-assigned gender or pursuing medical intervention that will enable them to transition;
• in those who choose to live in their preferred transgender role, to start treatment, pausing for reflection before each step, first with puberty blockers, then with cross-sex hormones and finally with gender reassignment surgery to relieve gender dysphoria.

Among those who opt for medical treatment, the degree of success of intervention is measured by the absence of gender dysphoria and mental health problems and by the presence of psychological well-being. Ideally it would be possible to quote findings from a number of controlled trials of each of the interventions. Given the impracticability of obtaining agreement from children and young people with intense gender dysphoria to participate in controlled trials, the findings from uncontrolled but carefully conducted studies provide the main evidence for effectiveness.

There have now been a number of such uncontrolled studies, in which patients have been followed up to see whether their physical and psychological states have improved or deteriorated after the use of puberty blockers alone 24 – 26 and puberty blockers followed by cross-sex hormones followed by surgery. 27 – 29 The most recently published study of the effects of puberty blockers was reported from the Portman Clinic, London. 30 This study reported on the short-term outcome over 2 years of 44 children and young people aged 12 to 15 years when they started treatment with puberty blockers. Overall, the patient experience was positive. Although there were some children who showed some negative outcomes in mood and quality of relationships with family and friends, the majority showed positive change. There was no change in the rate of parent- or child-rated behaviour problems or risk of self-harm. All adverse effects, when they occurred, were mild. In line with other studies, only 1 of the 44 children and young people treated with puberty blockers did not go on to request cross-sex hormone treatment.

All the studies quoted above have provided valuable information. In all cases, there has been benefit from the interventions for the majority and an absence of significant harm. The most recent critical review of the use of puberty blockers has concluded: ‘Although large long-term studies with diverse and multicultural populations have not been done, the evidence to date supports the finding of few serious adverse outcomes and several potential positive outcomes. This literature suggests the need for transgender youth to be cared for in a manner that not only affirms their gender identities but that also minimises the negative physical and psychological outcomes that could be associated with pubertal development’. 31 In all published cases, the majority has reported benefit from the interventions and an absence of significant harm. Where it has been measured, an improvement in psychological well-being has always been found. It is well established that adults who transition ‘experience fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction’ than before the transition and show no wish to revert to their gender assigned at birth. 32

It should be added that the use of puberty blockers in early adolescence has been strongly criticised. 33 , 34 It has been claimed that there has been undue reliance on an affirmative approach (self-identification) in making a transgender diagnosis, that the complexity of the underlying problems of young people presenting as transgender has been inadequately assessed, that a high proportion of those who are treated with puberty blockers regret that they have received this treatment and that the young people who have been treated have not been capable of giving informed consent to treatment that has such profound implications for their future.

Adverse effects of medical interventions

The effect of puberty blockers is generally, though not universally, regarded as reversible. Their use has been associated with apparently reversible stunting effects on height velocity and bone maturation. 29 , 35 General cautions that have been expressed by clinicians about the possibility of irreversibility, such as those by Professor Butler and Dr de Vries quoted in a judicial review, 19 are no more than one might expect in relation to a large number of interventions in routine use. Caution about possible harm is always an appropriate clinical stance. It should not be taken to mean that the intervention in question should not be used where it is indicated.

There is one undeniable loss that occurs as a result of the use of puberty blockers. The individual does not go through the experience of the ‘normal’ adolescence he or she would have had without their use. However, most transgender young people do not consider this to be a loss or in any way regrettable.

The use of cross-sex hormones exposes the individual to the risk of a metabolic abnormality in about 15% of cases, but the significance of this finding is not clear and it does not seem a contraindication to their use. 36 Further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones.

Informed consent

The competence of young people to give informed consent to the use of puberty blockers and cross-sex hormones is currently a matter of great relevance to clinical management. In UK law, 16 years is regarded as the youngest age at which it can be assumed, on the basis of chronological age, that a young person can give informed consent to a medical procedure. Below that age, it is widely accepted that, in considering whether a young person is capable of giving informed consent, the so-called Gillick principle should be applied. This principle, expressed by Lord Scarman in a 1985 House of Lords judgment and repeated in the above-mentioned judicial review, 19 is that ‘as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to […] understand fully what is proposed’. There is a controversy as to whether, because of the unusually complicated issues involved, children under the age of 16 could ever have the cognitive competence to give consent to puberty blockers or cross-sex hormones. This matter was considered in great detail in the judicial review whose judgment was published in December 2020. 19 This court decided that young people under 16 years could not give informed consent to the use of puberty blockers. Further, the court ruled that, even in cases where parents give their informed consent and clinicians are in agreement, an application should be made to the courts for authorisation before a child under 16 years can be administered puberty blockers. However, on appeal, this decision was reversed. The Appeal Court decided that the initial judgment had placed an improper restriction on the Gillick test and that it would not be appropriate for an application to the courts to be required before a child could be administered puberty blockers. 37

There is a need for systematic psychological investigation into the capacity of children and young people to make decisions in this area. Although there is some evidence on the capacity of young people aged 14–16 years to understand medical procedures, there is no evidence relating to the specific question of their understanding of the use of puberty blockers and cross-sex hormones, for example, in comparison with that of older people. Such evidence should be obtained. In the meantime, it would seem reasonable to rely on the findings of Weithorn & Campbell, whose study provides the most relevant data. 38 These investigators looked at 24 individuals in each of four age groups: 9, 14, 18 and 21 years. They tested their competence to make informed treatment decisions in a series of medical dilemmas, involving conditions such as epilepsy, diabetes and psychological problems. The children, adolescents and young adults were given the nature of the problem, treatments options, expected benefits, possible risks and consequences of failure, and then assessed on how much they understood. The 14-year-olds did as well as the 21-year-olds. The 9-year-olds did distinctly less well. Although it is many years since this study was carried out, until more relevant evidence is produced, there is no reason why its findings should not be regarded as highly pertinent.

Conclusions

One can conclude from the evidence that gender dysphoria is a relatively rare but well-defined condition, characterised by a strong desire to be of the gender opposite to that assigned at birth and by an insistence that one is, indeed, of the other gender. Affected transgender individuals are usually aware of its existence by the age of 5 years. Gender dysphoria needs to be distinguished from gender-atypical behaviour, where those assigned male gender at birth showed an interest in activities generally preferred by girls and vice versa . Marked gender-atypical behaviour occurs in around 2–3% of the population, most of whom are not transgender. Further, many children who show gender dysphoria before puberty do not continue to do so during and after pubertal changes occur. However, if gender dysphoria does persist into adolescence, its intensity tends to increase at this time.

From about 2005 until the present, there has been a considerable, perhaps tenfold, increase in the number of children and young people referred to gender identity clinics. This change has been observed not just in the UK, but in Canada, the USA and Finland. These more recent referrals have differed from previous cases in three ways. More recent referrals have been older, often not presenting until the early teen years. Whereas previously referrals were relatively evenly balanced between those assigned male and female gender at birth, there is now a considerable preponderance of those assigned female gender at birth. Further, whereas previously children and young people with transgender did not show high rates of behavioural and emotional disturbance, this is not the case for recent referrals.

The assessment and management of gender dysphoria has been pioneered by a Dutch group based in Amsterdam. This group has laid down a number of principles of management, which have been widely adopted by gender identity clinics in other countries. The effectiveness of this sequence of interventions is now reasonably well established, with good evidence that it relieves gender dysphoria and usually improves psychological well-being. Physical side-effects may occur but as far as can be ascertained at present, not to a degree where possible harm outweighs benefit. There are, however, unresolved issues concerning the capacity of young people with gender dysphoria to give informed consent to the use of puberty blockers.

There are a number of gaps in knowledge requiring urgent attention. First, it is unclear whether the considerable increase in referrals to gender identity clinics in the past 15 years is due to greater willingness of early affected individuals to come out at this age or whether clinics are dealing with a different population with different needs. There is clearly a need for both quantitative and qualitative research to investigate the early histories of those assigned female gender at birth referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years. Second, although it is reasonably well established that the use of puberty blockers is not accompanied by serious adverse effects, further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones. Finally, there is a need for research into the capacity of children and young people, compared with older people, to understand the implications of the use of puberty blockers and cross-sex hormones.

About the author

Philip Graham is Emeritus Professor of Child Psychiatry in the Institute of Child Health, University College, London, UK.

Data availability

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of interest