gender dysphoria reassignment surgery

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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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What is gender-affirming surgery?

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

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

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

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

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

Why choose Ohio State for gender-affirming surgery?

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

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Gender-Affirming Surgery (Top Surgery)

Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as “top surgery" and "bottom surgery.” Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their appearance to align with their internal identity. If, after a consultation with our doctors, you decide to pursue top surgery, we work toward a positive outcome that improves your physical, emotional, and psychological well-being.

What You Should Know About Gender-Affirming Surgery

Choosing to pursue gender-affirming surgery is an individual, personal decision. You’ll want to consider how it will change your quality of life and how it will help you achieve your goals.

Gender Dysphoria One important step is understanding how much you are affected by gender dysphoria, a diagnosis that the American Psychiatric Association defines as a conflict between your physical or assigned gender and the gender with which you identify. 

Candidates for Top Surgery To be a candidate for top surgery, you must:

• Be 18 or older
• Be in good health without illness or a condition that can increase your risk of surgical complications
• Have a BMI under 35
• Provide a clearance letter from your mental health or primary care provider stating you have gender dysphoria and you have been living in your assigned gender for at least 12 months

Top Surgery Costs Some private insurance plans will cover transgender surgery when it is used to address a diagnosis of gender dysphoria. Check with your insurance plan to determine your coverage.

Understanding Which Top Surgery Is Right for You There are several approaches to transgender surgery. We will review these with you during your initial consultation and make a recommendation based on your physical exam and medical history.

You May Have Scars Your surgeon will use the natural contours of your breasts to minimize scarring as much as possible. In some cases, depending on your breast size and weight, a small bunching of tissue may result in scars known as “dog ears” following mastectomy. These can be corrected later with revision surgery.

Understand the Risks Top surgery carries the same risks as other standard surgeries. These include the risk of bleeding and infection and risks associated with general anesthesia. Your doctor will discuss these risks with you if surgery is recommended.

Initial Consultation and Tests

Consultation and Exam Your first step will be an in-person consultation. Our providers spend time meeting with you, evaluating your anatomy, answering your questions, and determining if this surgery will help you achieve your goals.

Your surgeon will review your family history, general health status, lifestyle habits such as smoking, previous operations, any medications you may be taking, and conditions that can put you at risk for surgery.

Measurements, Photographs, Tests Your breasts will be measured and assessed for size and shape, and photographs may be taken for your medical record. Before treatment is recommended, you will also undergo one or more of the following tests.

• Blood tests may be necessary to evaluate your hormone levels. Pre-surgical testing also requires several blood tests to assess your liver and kidney function and to determine if you have a previously undetected infection, blood disorder, or anemia.
• A mammogram may be performed to look for any underlying breast abnormalities. Additional imaging, including ultrasound and MRI, may also be requested.

Recommending Treatment Based on these findings, your surgeon will recommend an approach to surgery. She will discuss the expected outcome, potential risks and complications, and your post-operation recovery. Alternatively, your surgeon may recommend that you lose weight, quit smoking, or discontinue medication before surgery to ensure you experience the best possible outcome.

If You Take Hormone Therapy Some gender-affirming hormone therapy , such as testosterone, can be continued if you pursue transgender surgery. Others, such as anti-estrogen therapy, may be stopped. Your surgeon will explain what you need to do to prepare for surgery.

Top Surgeries

Chest reconstruction - mastectomy, breast reduction.

We use different approaches to remove breast tissue and contour breasts to appear more masculine. The right approach depends on your anatomy and the size of your breasts. Techniques for medium to large breasts include nipple-sparing, double incision, buttonhole, and inverted-T incision. Keyhole and peri-areolar techniques may be used for smaller breasts or for those with good skin elasticity. Your surgeon will discuss your options with you after your physical exam and consultation.

Breast Augmentation

There are also many different approaches to breast augmentation, including the use of implants and fat grafting. We can also combine breast augmentation with body contouring, liposuction, and neurotoxin injections such as Botox injections and dermal fillers.

The Procedure Length

On average, top surgery takes about two to three hours and is performed under general anesthesia in an outpatient ambulatory surgery center. In some case, an overnight stay may be required. Sometimes a second procedure is needed to further tighten skin and achieve optimal cosmetic results.

Your chest will be wrapped in bandages, and a compression chest vest or surgical bra will be worn after the procedure. Drains will be required after mastectomy but not after breast augmentation. Initial recovery takes about one week. It may take three to six months for all swelling to subside and scars to fade.

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 9 pediatric specialties by U.S. News & World Report for 2023–2024.

Why Choose Duke

You'll Work With a Plastic Surgeon Experienced in Gender Affirmation Surgery Our plastic surgeon has worked with many individuals seeking gender confirmation surgery. She is fellowship trained in body contouring, which means she has completed additional training in procedures that improve the body shape. Our surgeon is also a member of the World Professional Association for Transgender Health (WPATH), a nonprofit organization working to standardize and improve transgender care.

Duke Health Is Committed to the LGBTQ+ Community Duke Health values diversity and has taken many steps to show its commitment to eliminating discrimination, promoting equality, and standing beside our lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. Duke University Hospital, Duke Regional Hospital, and Duke Raleigh Hospital are recognized as LGBTQ+ Healthcare Equality Leaders by the Human Rights Campaign Foundation for perfect scores across areas of patient-centered care, support services, and inclusive health insurance policies for LGBTQ+ patients.

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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

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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

Affiliations.

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

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

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

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

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

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

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

• Patient Care & Health Information
• Diseases & Conditions
• Gender dysphoria

Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics.

Transgender and gender-diverse people might experience gender dysphoria at some point in their lives. However, some transgender and gender-diverse people feel at ease with their bodies, with or without medical intervention.

A diagnosis for gender dysphoria is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual published by the American Psychiatric Association. The diagnosis was created to help people with gender dysphoria get access to necessary health care and effective treatment. The term focuses on discomfort as the problem, rather than identity.

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Gender dysphoria might cause adolescents and adults to experience a marked difference between inner gender identity and assigned gender that lasts for at least six months. The difference is shown by at least two of the following:

• A difference between gender identity and genitals or secondary sex characteristics, such as breast size, voice and facial hair. In young adolescents, a difference between gender identity and anticipated secondary sex characteristics.
• A strong desire to be rid of these genitals or secondary sex characteristics, or a desire to prevent the development of secondary sex characteristics.
• A strong desire to have the genitals and secondary sex characteristics of another gender.
• A strong desire to be or to be treated as another gender.
• A strong belief of having the typical feelings and reactions of another gender.

Gender dysphoria may also cause significant distress that affects how you function in social situations, at work or school, and in other areas of life.

Gender dysphoria might start in childhood and continue into adolescence and adulthood. Or you might have periods in which you no longer experience gender dysphoria. You might also experience gender dysphoria around the time of puberty or much later in life.

Complications

Gender dysphoria can affect many aspects of life, including daily activities. People experiencing gender dysphoria might have difficulty in school due to pressure to dress in a way that's associated with their sex assigned at birth or out of fear of being harassed or teased.

If gender dysphoria impairs the ability to function at school or at work, the result may be school dropout or unemployment. Relationship difficulties are common. Anxiety, depression, self-harm, eating disorders, substance misuse and other problems can occur.

People who have gender dysphoria also often experience discrimination, resulting in stress. Accessing health services and mental health services can be difficult due to fear of stigma and a lack of experienced care providers.

Adolescents and adults with gender dysphoria without gender-affirming treatment might be at risk of thinking about or attempting suicide.

Gender dysphoria care at Mayo Clinic

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• Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Nov. 8, 2021.
• Keuroghlian AS, et al., eds. Nonmedical, nonsurgical gender affirmation. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Nov. 8, 2021.
• Coleman E, et al. Surgery. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Version 7. World Professional Association for Transgender Health; 2012. https://www.wpath.org/publications/soc. Accessed Nov. 3, 2021.
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Treatment - Gender dysphoria

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

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

Treatment for children and young people

If your child is under 18 and may have gender dysphoria, they'll usually be referred to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust.

GIDS has 2 main clinics in London and Leeds.

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

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

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

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

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues
• a referral to a specialist hormone (endocrine) clinic for hormone blockers for children who meet strict criteria (at puberty)

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

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist) to see if they can take hormone blockers as they reach puberty. This is in addition to psychological support.

Puberty blockers and cross-sex hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) pause the physical changes of puberty, such as breast development or facial hair.

Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.

Although GIDS advises this is a physically reversible treatment if stopped, it is not known what the psychological effects may be.

It's also not known whether hormone blockers affect the development of the teenage brain or children's bones. Side effects may also include hot flushes, fatigue and mood alterations.

From the age of 16, teenagers who've been on hormone blockers for at least 12 months may be given cross-sex hormones, also known as gender-affirming hormones.

These hormones cause some irreversible changes, such as:

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

Long-term cross-sex hormone treatment may cause temporary or even permanent infertility.

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

There is some uncertainty about the risks of long-term cross-sex hormone treatment.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from GIDS.

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

Treatment for adults

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

Find an NHS gender dysphoria clinic in England .

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

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

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

Hormone therapy for adults

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

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

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

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

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

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

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

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

Risks of hormone therapy

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

The most common risks or side effects include:

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

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

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

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

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

Read more about fertility preservation on the HFEA website.

Surgery for adults

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

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

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

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

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

Surgery for trans men

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

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

Gender surgery for trans men includes:

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

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

Surgery for trans women

Gender surgery for trans women includes:

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

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

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

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

Life after transition

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

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

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

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

NHS guidelines for gender dysphoria

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

• Non-surgical interventions for adults
• Surgical interventions for adults
• Services for children and young people (PDF, 1.15Mb)
• Amendments to services for children and young people (PDF, 16kb)

Review of gender identity services

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

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

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• v.10(3); 2022

Gender Dysphoria and Its Non-Surgical and Surgical Treatments

Danyon anderson.

1 Medical School, Medical College of Wisconsin

Himasa Wijetunge

2 School of Medicine, Louisiana State University Health Sciences Center

Peyton Moore

3 School of Medicine, Louisiana State University Health Science Center

Daniel Provenzano

Jamal hasoon.

4 Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School

Omar Viswanath

Alan d. kaye.

Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one’s gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.

Introduction

Gender dysphoria, also known as gender incongruence, is a condition that occurs when an individual’s gender identity differs from their biological sex. This condition can cause severe physical and psychological stress.

One recent report finds that 1.4 million individuals or 0.6%, of the adult U.S. population identifies as transgender. 1 Another meta-analysis finds that prevalence is drastically different depending on how transgender is defined. There is a higher prevalence of people who self-report as transgender than there are of patients who are being treated for gender dysphoria. 2,3

The pathophysiology of gender dysphoria is something under active investigation. There are twin studies with small sample sizes that demonstrate a genetic component of gender identity. 4 There is also evidence of neuroanatomical differences among transgender individuals. 5–7

A diagnosis of gender dysphoria can be made if a patient is experiencing gender incongruence that causes significant distress. Individuals typically present with gender dysphoria during adolescence, but it is not uncommon for patients to present in early childhood or after the age of 18. 8,9

Patients with gender dysphoria who receive treatment report happier lives. There is also a decreased rate of suicidality among patients who receive appropriate gender affirmation treatment. 10 Treatment starts with hormone therapy. Patients who have received hormone therapy for a year may qualify to undergo gender confirmation surgery. Adverse effects of certain treatments, especially surgical, can be significant.

This review paper aims to update the reader on the most recent research of all aspects of gender dysphoria.

Epidemiology

It is estimated that there are 25 million transgender people worldwide. 11 Determining the prevalence of gender dysphoria and transgenderism is difficult as it varies based on the definition used. For example, there is a much higher prevalence of people who self-identify as transgender compared to people who have received hormone therapy or gender affirmation surgery. 2,3 Exact prevalence is difficult to quantify due to differences among geographical areas. One report shows that the prevalence among the total U.S. population is about 0.6%, but if broken down by state, it varies from 0.3%-0.76%. 1 This also holds true when comparing epidemiological studies of gender dysphoria across different countries. 3,12 Recent data shows that there has been an increase in the prevalence of individuals seeking treatment for gender dysphoria. 13 The aforementioned report shows that the prevalence of Americans identifying as transgender has doubled over the last 10 years. 1 The biggest increase is among children and adolescents. 14 It is unclear if this is due to an actual increase in the number of individuals with gender dysphoria or a societal shift towards openness and acceptance of variations in gender identity. Prior to the overall increase in prevalence, the sex ratio once favored birth assigned males to, now, favoring birth assigned females. 15 Recent data also suggests that individuals typically experience their first gender dysphoria symptoms by age 7 and often live for over 20 years before seeking treatment. 16

Pathophysiology/Risk Factors

There is growing evidence for a broad biological basis of gender identity. A variety of studies show evidence of genetic links, neuroanatomical differences, and prenatal androgen exposure that affect gender identity. Data in this field is more recent, as older studies mostly focused on psychosocial aspects of gender identity and gender dysphoria.

Genetic evidence is based on studies of sex hormone signaling genes and twin concordance studies. Foreman et al. finds statistically significant genetic differences in sex signaling genes in transgender women compared to cisgender males. These differences include differences in alleles, genotypes, and allele combinations mostly involving androgen receptor genes. 17 There are many, mostly small, twin heritability studies of gender dysphoria with a recent review showing that most estimates of heritability fall in the range of 30-60%. 18 Combined, this data supports a polygenic component of gender identity.

Neuroanatomical studies show the brains of gender dysphoric individuals resemble the gender they identify with as opposed to those of the gender they were assigned at birth. Studies in this field are mainly neuroimaging studies that find increased cortical thickness, and weaker connections in regions of the brain known for processing one’s own body perception. 5–7 More recently, brain connectivity studies find that brain connectivity dynamics are similar among transgender individuals and the gender they identify with than with the gender they were assigned at birth. 19 While more studies need to be done to further elucidate the neuroanatomy and neurophysiology, the current research suggests that brain architecture and function play an important role in gender identity and gender dysphoria.

It is well established that androgens play a crucial role for the development of sex characteristics, sexual, and gender identity. 20,21 Studies show that women exposed to high levels of androgens due to congenital adrenal hyperplasia (CAH) are more likely to be dissatisfied with their gender assigned at birth. 20 On the other hand, patients with complete androgen insensitivity (CAIS) typically express female gender identification. 22 These individuals are XY, but develop female secondary sexual characteristics, and most often identify as females. This occurs due to androgen receptor defects which lead to androgen resistance. CAIS patients also have undescended male testis which cause them to have male levels of testosterone. Data from these patients shows a clear link between androgen exposure and gender identity.

There are also psychosocial factors that are associated with gender dysphoria. Early researchers hypothesized that gender dysphoria development was due to certain parental influences such as lack of paternal reinforcement and paternal absence among other factors. Some of these hypotheses have been tested but the data are not conclusive. 23,24 More recent data show that elevated levels of psychopathology in parents and childhood anxiety increase risk for development of gender dysphoria. 25,26 Overall, studies on the psychosocial factors of gender dysphoria are older and more scarce than recent data on the biological factors regarding gender identity.

Clinical Presentation and Diagnosis

Gender dysphoria has become progressively more common and has been recognized and treated earlier over the last two decades. 27 The presentation and diagnosis of these individuals can often be a challenge due to the sensitive nature of the topic. These individuals often present in their adolescent and teenage years when their gender identity. 28 In studies of adolescents done in China, there was a high correlation between those who identified as transgender and non-binary and high scores on the generalized anxiety disorder scale as well as the suicidal ideation assessment. Early detection of adolescents with gender dysphoria helps establish psychiatric treatment of comorbid depression and anxiety. 29 The Diagnostic and Statistical Manual for Mental Disorders 5 th edition (DSM-5) defined two criteria for the diagnosis of gender dysphoria in adolescents. The first is defined by “A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:

• a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics);
• a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
• a strong desire for the primary and/or secondary sex characteristics of the other gender.
• a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
• a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
• a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)“.

The second criteria states that “The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning”. 30 Most often these adolescents present during the early stages of puberty with incongruence between sex assigned at birth and gender identity. 31 This can present as many different behaviors such as changing one’s hair, clothing, behaviors, or name to match their preferred gender. Distress can be observed as outbursts against parents or peers who may attempt to make the child conform to their birth sex. 32 Distress may also present as the child being resistant towards going to school through means of pretending to be sick. Distress may also present as signs of physical abuse from bullying such as bruises or scrapes. 27 Studies done in Germany showed that 26% of patients that presented to the clinic with gender dysphoria endorsed negative responses to their outings at school. 33 Comorbid depression and anxiety might also prompt patients to present to clinic, and further questioning is often required to reveal underlying gender dysphoria. 28 Treatment of underlying anxiety and depression is important in individuals who suffer from gender dysphoria as they have been shown to have higher rates of attempted and completed suicide compared to cis-gender counterparts. Studies also show that individuals who received gender-affirming treatment at younger ages had less suicidal ideation than those who received treatment later. 34 While it is most common for gender dysphoria to present in early teenage years, it is not uncommon for individuals to present in early adulthood. Almost 25-30% of patients with gender dysphoria present after the age of 18. In many of these cases, pressures from peers and family often delays presentation and treatment. 35 Another common risk factor for individuals with gender dysphoria is a history of childhood trauma. A survey conducted of 95 transgender individuals who previously self-reported having symptoms of gender dysphoria showed that 56% of these individuals experienced four or more early traumatic events in their childhood. Most often, these experiences were physical or emotional abuse from parents. Trans women had more events involving physical and psychological abuse from their father while being separated from their mothers. Trans men had more events involving their mothers and were frequently separated from and neglected by their father. 36 Studies have also shown that children who experience trauma early in life are more likely to develop disorganized attachments. This makes children more likely to develop dissociative and avoidant strategies for dealing with complex emotions and thoughts such as gender identity incongruence. Children and adolescents with significant history of trauma present later and are less likely to present to clinicians for evaluation. 37

Several tools have been developed to help clinicians diagnose gender dysphoria. These tools include self-surveys that can be given to patients to assess thoughts and symptoms of gender dysphoria. The most common and well-studied of these questionnaires is the gender identity/gender dysphoria questionnaire for adolescents and adults (GIDYQ-AA). This questionnaire has been verified to aid in the identification of individuals with gender dysphoria. The questionnaire has a sensitivity of 90.4% in the 73 transgender patients and a 99.7% specificity for the control group which included 389 university students that were both heterosexual and homosexual. 37 Additionally, the generalized anxiety disorder assessment (GAD-7) and the patient health questionnaire (PHQ-9) should be used in all adolescents, but this is particularly important in patients with gender dysphoria due to their higher incidence of anxiety and depression. 33 Many other tools have been recently developed to help diagnose and assess gender dysphoria. The gender identity reflection and rumination scale was developed to assess how often a person thinks about their gender identity. Higher scores correlated to more thoughts on gender identity which in turn correlated to higher frequencies of gender dysphoria. 38,39 Another aspect of the prognosis of adolescents with gender dysphoria is their sense of belonging they feel with their home community. Many studies have shown that trans-gender individuals who feel accepted in their communities or home have lower incidences of comorbid anxiety, depression, and suicide than those who are raised in communities where they feel mistreated. 40

The treatment for gender dysphoria is often multi-disciplinary, combining the efforts of several behavioral health and medical professionals. The World Professional Association for Transgender Health (WPATH) has developed recommended standards of care for treatment, and it’s clearly stated that these standards are “flexible” clinical guidelines. 41 The importance of this flexibility is to ensure individuality in treatment, as each patient may present with different goals or needs. The treatments can be divided into two main categories: non-operative and operative. Non-operative treatment focuses on implementing psychosocial therapy and/or medical management with hormone replacement therapy. Operative treatments range from small cosmetic procedures to much larger genital transformation surgeries. It is important to consider that an individual’s overall treatment may require a combination of both operative and non-operative practices.

Non-Operative Treatment: Psychosocial Therapy

Of the many recommended treatments for gender dysphoria, the first non-operative option is psychosocial therapy and counseling. The overall goal of psychosocial therapy is to improve the patient’s quality of life through open and consistent communication. 41 There are numerous aspects to this, but the objective is to support patients as they begin to implement their gender identity to their loved ones and society. Mental health professionals provide support by answering questions and discussing body image regarding the society-based gender normative. In addition, these professionals guide patients with coming out to friends, family, and colleagues. 42 The true benefit to therapy is that it is ongoing, rather than a single experience; patients can utilize this support lifelong, which is a key component to maintaining positive outcomes. For those who may not have access to a mental health professional, numerous support systems exist, including peer groups and internet-based support groups. 43 The WPATH recognizes that psychotherapy successfully helps individuals with their gender identity without needing hormone based medical therapy or gender affirmation surgery. 41,42

Non-Operative Treatment: Hormone Replacement Therapy

The second non-operative treatment option is medical management with hormone replacement therapy (HRT). According to the WPATH, numerous hormone combinations have been used in the treatment of gender dysphoria, however the data lacks an established standard regiment. 41 HRT requires a very in-depth pre-treatment work-up, which includes risk screening, thorough history and exam, as well as numerous laboratory studies to evaluate the patient’s ability to safely tolerate hormone replacement. 44 Some aspects of this pre-treatment work-up include medical and family history accessing for previous cardiovascular or thromboembolic disease, exam findings including weight, blood pressure, and secondary sexual characteristics, and finally laboratory testing focused on blood, liver, and current hormonal function. 45 It is imperative to confirm the diagnosis and ensure that a written indication for HRT is established by a psychotherapist or psychiatrist. 44 The goal of hormone replacement therapy is to promote the characteristics of the patient’s desired gender while minimizing the characteristics of their biological gender. 42

We will first discuss feminizing therapy for male-to-female (MTF) gender dysphoria. Feminizing HRT generates the following effects on the genetically male body: it softens the skin, decreases body hair production, reduces muscle mass, reduces testicular size, and encourages breast growth. The onset of these effects may begin within 6 months, while the maximum effects are expected to take place between 1-2 years. 41,45,46 These effects are achieved with a combination of pro-estrogen and anti-androgen therapy. Several sources suggest that treatment with physiologic doses of estrogen alone is insufficient to suppress testosterone to the level of a normal female, hence the addition of anti-androgen therapy is needed. 46,47 Pro-estrogen therapy involves the oral or transdermal administration of 17β-estradiol, which activates estrogen receptors and produces the effects listed previously. The recommended anti-androgen therapy is spironolactone, which is an androgen receptor antagonist that is very effective at inhibiting the actions of testosterone; it also has some estrogenic activity. 48 Supplementing synthetic estrogen has its risks, and it is very important for clinicians to monitor serum estradiol levels routinely every 3 months. Although the risk of adverse effects is controversial, the data supports that elevated levels of blood estrogen may lead to increased risk of liver disease, cardiovascular disease, hypertension, hyperprolactinemia, hypertriglyceridemia, and thromboembolic events. 41,44,45,49

The next discussion will be on masculinization therapy for female-to-male (FTM) gender dysphoria. This treatment is generally less complex than MTF therapy. Here, the primary hormone supplemented is testosterone. Several medications are available, which include testosterone enanthate and testosterone cypionate. These two specifically are administered via intramuscular injection, but other options are available that are administered via transdermal gels or patches. Administering testosterone activates androgen receptors which produces the following effects on the genetically female body: increased skin oiliness, increased facial and body hair production, increased muscle mass/strength, redistributed fat, halted menses, deepened voice, enlarged clitoris, and vaginal atrophy. 50,51 With FTM therapy, supplementing with testosterone provides individuals with the desired body changes. Anti-estrogen therapy is not needed to achieve the physiologic levels of testosterone in the normal male. This is what makes FTM therapy less complex than MTF therapy. 41,46 With testosterone supplementation, the adverse risks to screen and monitor for include erythrocytosis, liver disfunction, cerebrovascular disease, coronary artery disease, and breast or uterine cancer. 44,46,47,49

Operative Treatment

Many patients with gender dysphoria require some form of surgery to fully achieve their desired body image and psychological gender identity. These procedures, both genital and non-genital, are collectively known as “Gender Confirmation Surgery” (GCS). Genital surgeries specifically are often the last recommended as part of the overall treatment of gender dysphoria. This is due to permanent alteration in fertility, as well as the risks that are associated with surgery in general. When applicable, GCS can be utilized by health care experts to enhance patients’ gender identities in ways that psychotherapy and HRT may not be able to. 42,52 The WPATH recommends patients undergo some form of social transition utilizing psychotherapy and HRT prior to considering surgical treatment, but it is not a requirement for all procedures. 1 However, the WPATH has specific criteria for genital GCS, and this includes having at least 2 referrals from separate medical health professionals and complete patient compliance with at least 12 months of continued HRT. It is important to note that GCS is performed by many surgical fields, including plastic surgery, urology, otolaryngology, gynecology, and general surgery. 41,52

Operative Treatment: Non-Genital Feminization

There are several methods in which transgender women can surgically enhance their body image. The following are some of the procedures available: hair reconstruction and removal, voice modification, lipofilling, botulin toxin injections, mammoplasty, breast augmentation, gluteal augmentation, waist lipoplasty, and facial plastics. Facial plastics is the most sought after and contains an extensive array of options for patients. Some of the procedures that specifically fall under facial plastics include lip filler, face lifts, rhinoplasty, sinus surgery, forehead cranioplasty, supraorbital ridge reduction, mandibular reduction, and genioplasty. 50,53,54 There are several sources confirming that patients who undergo non-genital feminization surgery have high satisfaction rates and these procedures are often more desired compared to genital reconstruction surgery. 41,42,49,54

Operative Treatment: Genital Feminization

The most important aspect to determining which type of genital feminization surgery a patient desires is whether the patient is wanting penetrative ability. If an individual desires just the feminine appearance without penetrable ability, the recommend procedure would be a bilateral orchiectomy with a penectomy and urethroplasty. The orchiectomy would remove the main source of endogenous testosterone production, while the penectomy and urethroplasty would remove the penis and leave a proper functioning urethra. If a natural appearing vulva without penetrative ability is desired, then the recommended surgery here would be a vulvoplasty with clitoro-labioplasty. Finally, if a patient desires the natural vulva appearance with penetrative ability, an even more complex procedure is recommended. Here, the surgeon would perform the previously mentioned procedures with the addition of a vaginoplasty. 52 The vagina would be created either by inverting the penile skin or utilizing an intestinal graft while the vulva will be shaped using various skin graft techniques. 55 There are numerous complications that may arise from these invasive procedures. The more prevalent complications include neovaginal bleeding, discharge, introital stenosis, misdirected urinary stream, urinary incontinence, would healing disorders, and infection. 56–58

Operative Treatment: Non-Genital Masculinization

As compared to feminization surgery, there are fewer non-genital procedures performed for masculinization. The most popular and sought-after procedures involve masculinizing the chest which consists of subcutaneous mastectomy, chest contouring, pectoral implanting, and breast augmentation. For facial plastics, the most performed masculinization procedures are genioplasty, liposuction, and facial hair transplantation. 42,44,52,55 As with feminization, these non-genital masculinization procedures have high satisfactory rates from patients when combined with the additive effects HRT produces. 41,42,49,54 This is likely due to HRT for masculinization providing enough of an effect to reduce existing feminine characteristics.

Operative Treatment: Genital Masculinization

For genital altering masculinization, many transgender males prefer to start with removal of their biological reproductive organs. This consists of a complete hysterectomy, oophorectomy, and vaginectomy. Doing so permanently eliminates fertility and terminates menstruation; the termination of menstruation is one of the most desired outcomes. To achieve standing micturition, transgender males may undergo urethral lengthening. If the appearance of external male genitalia is desired, more complex procedures are required, such as metoidioplasty or phalloplasty with a scrotoplasty. The combination of these procedures allows transgender males to fully replicate external male genitalia. 58,59 As with feminization genital surgery, similar risks and complications exist with masculinization genital surgery which include including urinary incontinence, would healing disorders, and infection. 42,56,59

In recent decades, changes in the acceptance of variations in gender identity have facilitated more individuals openly expressing themselves as transgender. This is evident by the increasing number of people who identify as transgender over the past decade. 1 There is also an increasing body of evidence of a biological basis of gender identity. The rate of increase of prevalence of transgender individuals has been highest among children and young adolescents. 14 These patients will often first present to their primary care providers (pediatricians in this case) with either complaints of depression or anxiety from suffering with their identity crisis, or questions or desire about gender transition treatment. Treatment decreases suicidality among individuals with gender dysphoria and leads to improved quality of life. 10 Treatment options include psychosocial therapy, medical treatment for underlying depression and/or anxiety, hormonal treatment, and more than a dozen possible surgical procedures. More invasive treatments are associated with more severe adverse effects. Gender identity research is increasing rapidly, but there are still gaps in knowledge. Also, there is a need for large studies of long-term health outcomes of transgender individuals receiving medical and/or surgical treatment for gender dysphoria. Overall, this review paper provides the most up to date information regarding gender dysphoria and its treatments.

• 1. Flores AR, Herman JL, Gates GJ, Brown TNT. How Many Adults Identify As Transgender in the United States? Williams Inst . 2016;(June):13.
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Gender Dysphoria and Gender Reassignment Surgery

Tracking information, description information.

Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

A.     General

Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a person's gender identity.

B.     Nationally Covered Indications

C.    Nationally Non-Covered Indications

D.    Other

The Centers for Medicare & Medicaid Coverage (CMS) conducted a National Coverage Analysis that focused on the topic of gender reassignment surgery. Effective August 30, 2016, after examining the medical evidence, CMS determined that no national coverage determination (NCD) is appropriate at this time for gender reassignment surgery for Medicare beneficiaries with gender dysphoria. In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.

(This policy last reviewed August 2016.)

Transmittal Information

03/2017 - Effective Date: 08/30/2016. Implementation Date: 04/04/2017. ( TN 194 ) (CR9981)

National Coverage Analyses (NCAs)

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• Original Consideration for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N)

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

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U.S. Dept. of Health & Human Services

Gender Dysphoria and Gender Reassignment Surgery

This article is based on Change Request (CR) 9981, which informs MACs that coverage determinations for gender reassignment surgery will continue to be made by the local MACs on a case-by-case basis.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: March 03, 2017

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

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An October episode of Tucker Carlson’s show on X, formerly Twitter, focused on gender-affirming care for transgender people. In contrast to his guest’s claim, there are many long-term, peer-reviewed studies that examine the efficacy and effects of hormonal treatment in trans adults. 

Experts also say that Carlson’s comparison of gender-affirming surgeries and female genital mutilation is wrong. One is done with consent to preserve sexual function, the other is not. 

Carlson’s guest also made claims about the size of the trans health care market in billions of dollars. But experts say without knowing the methodology behind those calculations, it is hard to determine the estimate’s accuracy.

Since his firing from Fox News, former primetime host Tucker Carlson has taken his show on the digital road — to X, where he has interviewed public figures such as former President Donald Trump and independent presidential candidate Robert F. Kennedy Jr . 

On Oct. 4, Carlson released an episode titled "Trans, Inc" that focused on gender-affirming health care provided to transgender people. "Genital mutilation is not just a fad. It’s a full-blown industry," read the caption on Carlson’s X post sharing the episode. The 48-minute video criticized aspects of transgender health care, such as hormones, surgery and social affirmation. It describes "transgenderism" as "unnatural" and "demented," comparing it with "human sacrifice." Carlson could not be reached for comment. 

In the video, Carlson interviewed Chris Mortiz, whom Carlson introduced as a "policy guy" who has "taken a close forensic look at where the money is coming from." From his limited online presence, we found that Moritz has worked as a lawyer, investment banker and consultant. Mortiz did not respond to our requests for comment.  The video included some claims we have fact-checked before . But here are three new assertions involving hormone treatments, gender-affirming surgeries and the trans health care market. 

Moritz’s description of a total lack of research is inaccurate. The Endocrine Society’s Clinical Practice Guidelines state, "Prior to 1975, few peer-reviewed articles were published concerning endocrine treatment of transgender persons. Since then, more than two thousand articles about various aspects of transgender care have appeared." PolitiFact found several published and peer-reviewed studies examining the long-term effects and efficacy of cross-sex hormone treatment on bone health , cardiovascular risk, mortality , psychosocial functioning and more. There is enough research that we found systematic reviews — analyses of large numbers of individual research studies —  on specific aspects of treatment like bone health.

Although adolescent treatment for gender dysphoria started only in the late 1990s , transgender adults have received hormonal treatment and sex reassignment surgery since the early 1970s . 

Additionally, people who aren’t transgender, including men with low testosterone and women in menopause , sometimes rely on hormone therapy. 

"Hormone therapy for transgender males and females confers many of the same risks associated with sex hormone replacement therapy in nontransgender persons," the Endocrine Society’s Clinical Practice Guidelines say. 

The guideline outlines safe dosages and provides guidance for how physicians should monitor for potential adverse effects.

Female genital mutilation is a nonconsensual procedure that can include the partial or total removal of the clitoris, labia minora or the narrowing of the vaginal opening. The World Health Organization said it is mostly forced on girls younger than 15. More than 200 million women have been affected in 30 countries in Africa, Asia and the Middle East.

The procedure aims to reduce or eliminate sexual function and pleasure. It is widely considered a human rights violation. Dr. Marci Bowers, a gynecological surgeon who does gender-affirming genital surgeries and restorative surgeries for female genital mutilation survivors, told PolitiFact that gender-affirming surgeries do not amount to genital mutilation — the two are entirely different. "Transgender surgery is done with full consent of the individual," Bowers said. Female genital mutilation is usually forced on girls  younger than 15 in nonmedical and unsterile conditions. Gender-affirming surgeries, however, are performed in hospitals by trained professionals, and are rarely performed on people younger than 18, said Bowers, president of the World Professional Association for Transgender Health. When gender-affirming surgery is performed on minors, it is "only under the most severe conditions of gender dysphoria," she said.

Bowers also noted the difference in how the two procedures affect women’s sexual functionality — such as the ability to have sensation or orgasm. Gender-affirming surgeries "are generally quite elegant surgeries that leave the individual fully functional versus (female genital mutilation), which robs a woman of functionality," she said.

Mariya Taher, co-founder of Sahiyo , an organization working in Asia to end female genital mutilation, agreed with Bowers. Taher told PolitiFact her organization "strongly" believes that gender-affirming health care does not equate to genital mutilation.

"We are saddened to see the two issues are being conflated" and that female genital mutilation "is being used as a guise to target and harm trans youth and gender-diverse individuals" Taher said. Additionally, representatives from the End FGM network in both the U.S. and Europe told PolitiFact that female genital mutilation and gender-affirming surgeries are not the same.

We are unsure how Moritz arrived at those numbers; he offered no evidence backing them up and did not answer our inquiries.  We found a few publicly available market research reports, which are often commissioned by investors deciding whether to invest in a given industry. But it is difficult to assess the reliability of these reports without knowing the methodology behind them, and estimates can vary widely, said experts. Carlson made a broader assertion that profits are driving transgender health care: "Transgenderism, it didn't happen by accident," he said. "Some people are profiting from it."  

None of the 2022 reports we found for the U.S. market added up to $4.18 billion, but some got close. Grand View Research, for example, values the U.S. sex reassignment hormone therapy market at $ 1.6 billion and the U.S. sex reassignment surgical market at $ 2.1 billion in 2022. 

These values can be calculated using a combination of insurance data, federal and state data, and information directly from medical providers, explained Stephen Parente, professor of finance at the University of Minnesota Carlson School of Management. But for procedures not reimbursed by insurance, getting accurate estimates might prove more challenging. Coverage of health care services for transgender people can differ by state and health plan, according to HealthCare.gov .

"Most types of health care, including gender affirming care, involve multiple types of providers of goods and services — e.g., drugs, visits, procedures, hospital stays, etc." said Melinda Buntin, health economist and professor at Johns Hopkins Bloomberg School of Public Health. "For this reason, it is hard to assess how much is spent on specific categories of care in sum." The market size can vary depending on what is included in a given estimate, said Supriya Munshaw, associate professor at Johns Hopkins Carey School of Business. Is it just surgery or is the hospital stay included? What about complications? How do they determine what mastectomies are gender-affirming and which are done for breast cancer?

"How are you actually calculating the number?" said Munshaw. "It might differ in different research reports."

The U.S. health care market is large to begin with, totaling $4.3 trillion in 2021, according to federal data on national health expenditures . A market of billions is a "sizable market" from an investment perspective, Munshaw said, but "it doesn't mean that if something is profitable that the healthcare industry is pushing it." PolitiFact Researcher Caryn Baird contributed to this report. CORRECTION, Nov. 15, 2023:  Melinda Buntin is health economist and professor at Johns Hopkins Bloomberg School of Public Health. Her name was misspelled in an earlier version of this story.

Our Sources

Interview with Stephen Parente, Professor of Finance at the University of Minnesota Carlson School of Management, Nov. 14, 2023

Email interview with Melinda Buntin, health economist and professor at Johns Hopkins Bloomberg School of Public Health, Nov. 7, 2023

Interview with Supriya Munshaw, associate professor at Johns Hopkins Carey School of Business, Nov. 13, 2023

Email Interview with Mariya Taher, Co-founder and U.S. Executive Director of Sahiyo, Nov. 8, 2023

Email Interview with Caitlin LeMay, Director of End FGM US Network, Nov. 13, 2023

Email Interview with Myriam Mhamedi, Senior Communications and Campaign Officer at End FGM European Network, Nov, 10, 2023

Interview with Marci Bowers, Gynecological surgeon and President of the World Professional Association for Transgender Health, Oct. 12, 2023

Email interview with Jenni Gingery, Director of Communications and Media Relations at the  Endocrine Society, Oct. 12, 2023

X post ," Aug. 14, 2023

X post ," Aug. 23, 2023

X post ," Oct. 4, 2023

PolitiFact, " Rep. Mary Miller says White House is encouraging kids to take "castration" drugs, undergo surgeries ," April 17, 2022 

PolitiFact, " Ad goes too far with claim Joe Biden promotes surgery for trans teens ," Nov. 8, 2022

PolitiFact, " Puberty blockers: The facts and the myths ," Aug. 28, 2023

PolitiFact, " Rachel Levine does not support gender confirmation surgery for all children ," March 2, 2021

PolitiFact, " ‘Gender dysphoria’: What it is, what it isn’t and how history has changed its view ," May 22, 2023

PolitiFact, " No, California no separará a padres de hijos por debates de identidad de género ," Sept. 25, 2023

PolitiFact, " Is all gender-affirming care for children ‘experimental’? Experts say no ," Jan. 17, 2023

Endocrine Society, " Gender Dysphoria/Gender Incongruence Guideline Resources ," Sept. 1, 2017

Cleveland Clinic, " Low Testosterone (Low T): Causes, Symptoms & Treatment ," Sept. 2, 2022

Mayo Clinic, " Hormone therapy: Is it right for you? " Dec. 6, 2022

World Health Organization, " Female genital mutilation ," Jan. 31, 2023

UNICEF, " What is female genital mutilation? " accessed Nov. 14, 2023

PolitiFact, " Transition-related surgery limited to teens, not 'young kids.' Even then, it's rare ," Aug. 10, 2022

Sahiyo, " Home Page ," accessed Nov. 11, 2023

U.S. End FGM/C Network, " Home Page ," accessed Nov. 13, 2023

End FGM Europe, " Home Page ," accessed Nov. 13, 2023

Grand View Research, " U.S. Sex Reassignment Hormone Therapy Market Report, 2030 ," accessed Nov. 14, 2023

Grand View Research, " U.S. Sex Reassignment Surgery Market Size Report, 2030 ," accessed Nov. 14, 2023

HealthCare.gov, " Transgender health care coverage ," accessed Nov. 14, 2023

Centers for Medicare & Medicaid Services, " NHE Fact Sheet ," Sept. 6, 2023

Vision Research Reports, " U.S. Sex Reassignment Hormone Therapy Market Size, Growth, Trends, Report 2023-2032 ," accessed Oct. 16, 2023

Global Market Insights, " Sex Reassignment Surgery Market | Trends Report, 2023-2032 ,"  accessed Oct. 16, 2023 Global Market Insights, " Hormone Replacement Therapy Market Analysis | Forecast 2032 ,"  accessed Oct. 16, 2023

Clinical Endocrinology, " Mortality and morbidity in transsexual subjects treated with cross‐sex hormones ," Oct. 2003

European Journal of Endocrinology, " A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones ," April 2011

Journal of Bone and Mineral Research, " Bone Safety During the First Ten Years of Gender‐Affirming Hormonal Treatment in Transwomen and Transmen ," Dec. 2018

Journal of Clinical Medicine, " Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy ," June 2019

Journal of Clinical Medicine, " The ENIGI (European Network for the Investigation of Gender Incongruence) Study: Overview of Acquired Endocrine Knowledge and Future Perspectives ," April 2022

Metabolism Open, " The effects of gender-affirming hormone therapy on cardiovascular and skeletal health: A literature review ," March 2022

Nature Human Behaviour, " A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people ," May 22, 2023

Osteoporosis International, " Cortical and trabecular bone mineral density in transsexuals after long-term cross-sex hormonal treatment: a cross-sectional study ," Oct. 2004

PLoS One, " Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden ," Feb. 2011

The Journal of Clinical Endocrinology & Metabolism, " Bone Mass, Bone Geometry, and Body Composition in Female-to-Male Transsexual Persons after Long-Term Cross-Sex Hormonal Therapy ," July 2012

The Journal of Clinical Endocrinology & Metabolism, " Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal Experience ," Jan. 2008

The Journal of Sexual Medicine, " Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol ," March 2023

The Journal of Sexual Medicine, " Long-Term Evaluation of Cross-Sex Hormone Treatment in Transsexual Persons ," 2012

The Journal of Sexual Medicine, " The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets ," Feb. 2018

The Lancet - Diabetes & Endocrinology, " Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria ," Oct. 2021

Transgender Health, " A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals ," Jan. 2016

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Sex Reassignment Surgery Market Size to Hit of US$ 1,578.1 Million by 2030 at 12.4% CAGR | Exclusive Report by Coherent Market Insights

The global sex reassignment surgery market size is expected to reach US$ 1,578.1 Mn by 2030, from US$ 696.2 Mn in 2023, at a CAGR of 12.4% during the forecast period, as highlighted in a new report published by Coherent Market Insights.

Sex Reassignment Surgery, also known as gender confirmation surgery, is a medical procedure performed to change an individual’s physical characteristics to match their gender identity. This surgery allows transgender individuals to align their bodies with their true gender and alleviate gender dysphoria. The surgery may include various procedures such as breast augmentation or removal, genital reconstruction, facial feminization or masculinization, and voice surgery, among others.

Sample Pages of This Report @ https://www.coherentmarketinsights.com/insight/request-sample/6264

Market Dynamics:

The Sex Reassignment Surgery market is driven by two main factors. Firstly, the increasing demand for gender affirmation procedures among transgender individuals is a major driver for market growth. The growing acceptance and awareness of transgender rights have led to a greater demand for sex reassignment surgeries to align physical characteristics with gender identity.

Secondly, advancements in surgical techniques and technologies have significantly improved the safety and outcomes of sex reassignment surgeries. The introduction of minimally invasive procedures, such as laparoscopic and robotic-assisted surgeries, has reduced surgical complications and recovery time, leading to a higher demand for these procedures.

In conclusion, the Sex Reassignment Surgery market is poised for high growth in the coming years, driven by the increasing demand for gender affirmation procedures and advancements in surgical techniques and technologies.

TOP Players in Market Report are: –  Chettawut Plastic Surgery Center, Mount Sinai Centre for Transgender Medicine and Surgery, Rumercosmetics, Phuket International Aesthetic Centre, Yeson Voice centre, Bella Masena Clinic, Transgender Surgery Institute, McLean Clinic, Kamol Cosmetic Hospital, Dr. Alter Günter Clinic,  NYC Health + Hospitals/Jacob, Ram Manohar Lohia (RML) Hospital

Detailed Segmentation:

• Transgender Male to Female
• Transgender Female to Male
• Facial Feminization Surgery
• Breast Augmentation or Top Surgery
• Body Contouring
• Vaginoplasty
• Phalloplasty
• Metoidioplasty
• Specialty Clinics

Get a Discount on this Report @  https://www.coherentmarketinsights.com/insight/request-discount/6264  

Market Drivers for the Sex Reassignment Surgery Market

• Increasing Acceptance and Recognition of Gender Dysphoria

The growing acceptance and recognition of gender dysphoria as a legitimate medical condition have been instrumental in driving the sex reassignment surgery market. Gender dysphoria refers to the distress experienced by individuals whose gender identity does not align with the sex they were assigned at birth. Previously, many individuals with gender dysphoria faced social stigma and discrimination, making it difficult for them to access proper healthcare and treatment. However, societal attitudes have been evolving, with increased awareness and understanding, leading to greater acceptance and support for individuals seeking sex reassignment surgery.

As public awareness around gender dysphoria has increased, so has the demand for sex reassignment surgery. Many individuals have come forward to seek medical intervention to align their physical appearance with their gender identity. This has led to a surge in the number of individuals undergoing sex reassignment surgery, thus driving the growth of the market.

Furthermore, the growing recognition of gender dysphoria as a medical condition by healthcare professionals and insurance companies has also played a significant role in the market’s expansion. With more healthcare providers offering specialized gender-affirming services, individuals with gender dysphoria now have better access to comprehensive medical care, including sex reassignment surgery. Moreover, an increasing number of insurance companies are covering the cost of such surgeries, making them more accessible and affordable to a broader population.

• Technological Advancements and Medical Innovations

Technological advancements and medical innovations have greatly contributed to the growth of the sex reassignment surgery market. Over the years, surgical techniques and technologies used in sex reassignment surgeries have evolved significantly, leading to safer and more effective procedures. These advancements have enhanced patient outcomes, reduced complications, and improved the overall patient experience, thereby driving the market.

One such innovation is the use of laparoscopic and robot-assisted surgery in sex reassignment procedures. These minimally invasive techniques offer several advantages over traditional open surgeries, including smaller incisions, reduced postoperative pain, shorter hospital stays, and faster recovery times. Additionally, the advent of tissue engineering and regenerative medicine has opened up new possibilities for reconstructive procedures, such as neovaginal construction and phalloplasty.

Market Restraints for the Sex Reassignment Surgery Market

• High Costs of Sex Reassignment Surgeries

One of the significant restraints facing the sex reassignment surgery market is the high costs associated with these procedures. Sex reassignment surgeries involve a series of complex surgical procedures, including hormone therapy, mastectomy or breast augmentation, genital reconstruction, and facial feminization or masculinization. The overall cost of these procedures can be substantial, making them financially unattainable for many individuals, especially those without insurance coverage or limited financial resources.

Furthermore, insurance coverage for sex reassignment surgeries varies significantly across countries and even within different insurance plans. While some insurance policies cover the full or partial cost of these procedures, others may exclude them altogether, considering them as cosmetic or elective surgeries. This lack of consistent coverage further limits access to sex reassignment surgeries for many individuals, hindering the growth of the market.

• Limited Availability of Skilled Healthcare Providers

Another major restraint for the sex reassignment surgery market is the limited availability of skilled healthcare providers. Performing sex reassignment surgeries requires specialized training, expertise, and experience, as these procedures involve intricate anatomical reconstruction and gender-affirming care. However, the number of healthcare providers with the necessary skills and knowledge to perform these surgeries is relatively low globally, creating a bottleneck in access to care.

The limited availability of skilled healthcare providers can result in long waiting lists for sex reassignment surgeries, leading to delays in treatment and increased patient dissatisfaction. Moreover, it can also contribute to geographical disparities in access to care, with individuals in certain regions having to travel long distances to find suitable healthcare providers. To address this restraint, efforts should be made to expand the education and training programs in this field, as well as develop collaborative networks to ensure adequate access to skilled surgeons for individuals seeking sex reassignment surgeries.

Recent Developments:

✔ In November 2022, Bella Masena Clinic launched their advanced facial feminization services using cutting-edge 3D simulation software for better surgical planning and outcomes. ✔ In June 2021, Mount Sinai Health System opened the Center for Transgender Medicine and Surgery, providing a full suite of gender affirming procedures. ✔ In January 2020, Transgender Surgery Institute announced the launch of innovative penile preservation vaginoplasty technique for trans women. ✔ In October 2022, NYU Langone Health partnered with Emirates Airlines to make travel easier for international patients seeking gender affirmation procedures. ✔ In April 2021, Cleveland Clinic announced acquisition of Edgewater Surgery Center to expand its transgender surgery program. ✔ In September 2020, Chettawut Plastic Surgery partnered with Bangkok Hospital to provide patients with integrated transgender healthcare services.

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Table of Contents

Chapter 1  Market Overview 1.1 Definition 1.2 Assumptions 1.3 Research Scope 1.4 Market Analysis by Regions 1.5 Market Size Analysis from 2023 to 2030

Chapter 2  Competition by Types, Applications, and Top Regions and Countries 2.1 Market (Volume and Value) by Type 2.3 Market (Volume and Value) by Regions

Chapter 3  Production Market Analysis 3.1 Worldwide Production Market Analysis 3.2 Regional Production Market Analysis

Chapter 4  Sex Reassignment Surgery Sales, Consumption, Export, Import by Regions (2023-2023) Chapter 5  North America Market Analysis Chapter 6  Europe Market Analysis Chapter 7  Middle East and Africa Market Analysis Chapter 8  Asia Pacific Market Analysis Chapter 9  Latin America Market Analysis Chapter 10  Company Profiles and Key Figures in Sex Reassignment Surgery Business Chapter 11  Market Forecast (2023-2030) Chapter 12  Conclusions

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Coherent Market Insights  is a global market intelligence and consulting organization focused on assisting our plethora of clients achieve transformational growth by helping them make critical business decisions. We are headquartered in India, having sales office at global financial capital in the U.S. and sales consultants in United Kingdom and Japan. Our client base includes players from across various business verticals in over 57 countries worldwide. We create value for clients through our highly reliable and accurate reports. We are also committed in playing a leading role in offering insights in various sectors post-COVID-19 and continue to deliver measurable, sustainable results for our clients.

📌Contact Us: Mr. Shah Coherent Market Insights Pvt. Ltd, 📞Phone: U.S.: +1-206-701-6702 📞U.K.: +44-020-8133-4027 📞JAPAN: +81-50-5539-1737 📞INDIA: +91-848-285-0837 ✉ Email: [email protected]

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The Sydney Morning Herald

Health department to consider funding gender-affirming surgery under medicare, by natassia chrysanthos, save articles for later.

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Gender-affirming procedures such as chest surgery and genital reconfiguration would be subsidised by Medicare under a push to improve mental health and quality of life for transgender people.

The federal health department will consider an application from the Australian Society of Plastic Surgeons that seeks to establish 21 Medicare items for gender-affirming surgeries for people who have gender incongruence, in which a person’s experience of gender does not align with how they were born.

The application said gender-affirming surgery is already being performed in Australia but the system is fragmented and can have high out-of-pocket costs. Credit: Eddie Jim

The application to the Medical Services Advisory Committee says gender-affirming surgery – a catch-all term for procedures that align a person’s body with their gender identity – is already being performed in Australia but that the system is fragmented and can have high out-of-pocket costs.

It estimated there would be 64,101 transgender people who were born male and 64,044 transgender people who were born female who could be candidates for the procedures in Australia.

The procedures pitched for Medicare coverage include feminising chest surgery, which may involve inserting prosthetics or fat grafts, and masculinising chest surgery, which may or may not require repositioning nipples.

There are also proposed Medicare items for genital reconfiguration surgery, which could involve removing genitals or constructing a neo-penis or neo-vagina, as well as feminising or masculinising facial surgery and voice surgery.

The proposal, which will be considered at a meeting next month, suggests the Medicare rebates be limited to adults between 18 and 50 years old.

“Some medical interventions for gender affirmation are irreversible, may be associated with a risk of adverse effects, involve complex surgical procedures or have consequences on reproductive options after treatment,” it says.

People seeking gender-affirming surgeries currently deal with a mix of non-specific Medicare items or fund their treatment themselves, and they might pay more than $20,000 or go overseas to access surgery.

“The current funding arrangements for surgical procedures is highly fragmented,” the application says.

It says current Medicare item descriptors are a “poor fit” for gender-affirming surgeries that cause anxiety to doctors who used them, in case they are not appropriate, while other interventions are not subsidised when used for gender-affirming purposes.

“Despite the lack of [Medicare] funding, these procedures are well-established for the purposes of gender affirmation,” it says.

The fee list, to be based on existing rebates for similar procedures, is still being developed. The application gives examples suggesting a $1335.70 rebate for masculinising chest surgery, and that voice surgery can be covered by a $621.20 or $1006.55 rebate, depending on the type of procedure.

But the overall cost per patient would vary substantially depending on which procedures are performed.

The Australian Society of Plastic Surgeons declined a request for an interview. However, its application says legitimised and universal access to gender-affirming medical interventions is an important way of improving the mental health of transgender people and those with gender incongruence.

Australian studies have shown such people report higher rates of psychiatric conditions, suicidal ideation and suicide attempts than the general population. Other research shows gender diverse people report their quality of life significantly improved after undergoing gender-affirming surgery.

A 2021 petition for public funding of gender-affirming surgery was backed by almost 150,000 people, but then-health minister Greg Hunt in his response said no specific application had been made to list items through the Medicare Benefits Schedule.

The Australian Society of Plastic Surgeons wrote that its new application “directly addresses the gap identified by then Minister Hunt as a means to progress making gender-affirming services eligible for a Medicare benefit”.

Royal Australian College of GPs vice president Bruce Willett said the Medicare advisory committee had a vital role in weighing up evidence to carefully consider the application. “Patients should be able to access the care and treatments they need, regardless of income or postcode,” he said.

“There is next to no access to gender-affirming surgeries within the public system. Evidence suggests surgery can relieve gender dysphoria, improve patient mental health and quality of life, and potentially save lives. No one should be left behind, and that is exactly what can happen when people come up against long waiting lists for care.”

A Health Department spokesperson said the application would be considered by a sub-committee in December, before a likely assessment by the full advisory committee next year.

”The Australian government is committed to supporting Australians to access high-quality health care,” the spokesperson said. “There is a range of [Medicare] items that could be used at various stages of the gender-affirming process, including GP and specialist consultation items. [Medicare] rebates are also available for some surgical procedures which may be performed during gender affirmation process.“

Most Viewed in Politics

A newsletter briefing on the health-care policy debate in Washington.

SCOTUS is under pressure to weigh gender-affirming care bans for minors

Happy Monday morning, I hope everyone had a great Thanksgiving. Not a subscriber? Sign up here.

Today’s edition: Three local governments in Virginia are the latest to file lawsuits over skyrocketing insulin prices. How a stray kitten kicked off a sprawling effort to contain a lethal virus. But first …

Calls are mounting for the Supreme Court to consider gender transition care bans for teens and children

Pressure is building on the Supreme Court to weigh in on gender transition care for minors, as judges across the nation deliver clashing decisions on whether states can restrict it. 

Lawsuits seeking to overturn the bans prevailed in federal district courts initially, with judges blocking bans in Indiana and Florida from taking effect. Plaintiffs also saw early success in the U.S. Court of Appeals for the 8th Circuit, where a panel of three judges upheld a preliminary injunction temporarily blocking Arkansas from enforcing its restrictions. 

But the legal tide shifted in August when the U.S. Court of Appeals for the 11th Circuit allowed Alabama ’s gender-affirming care ban to take effect while a challenge to it proceeds. And in September, the U.S. Court of Appeals for the 6th Circuit did the same for similar rules in Tennessee and Kentucky . 

For several years now, the Supreme Court has been “basically dodging transgender constitutional rights cases,” said Katie Eyer , a professor at Rutgers Law School who is an expert on LGBTQ rights. “But I think it’s reaching a point where the court may have difficulties avoiding doing so [moving forward].” 

Twenty-two GOP-led states have passed restrictions on transition care for young people since 2021, sparking a heated debate over what’s known about the long-term impact as more children and teenagers seek such services. Gender-affirming care includes puberty blockers and hormone therapy, as well as surgery in limited cases. 

Demand for these services has skyrocketed in recent years; 13,000 transition-related surgeries were performed in the U.S.  in 2019, up from 4,550 in 2016, according to research published in the Journal of the American Medical Association. Most of the surgeries were performed on adults, but 8 percent of patients were ages 12 to 18.

Major U.S. medical associations oppose the GOP-backed bans, arguing that health-care decisions should be made by patients, their relatives and their doctors. But after England and Sweden recently placed limits on gender-related treatments for minors, the American Academy of Pediatrics commissioned a review of the existing research while reaffirming its support of such care.

Today, we’re looking into some of the ongoing legal battles over the wave of restrictions on gender-affirming care for minors, and previewing what the path to the Supreme Court might look like. 

In Arkansas 

Arkansas is the only state to have its ban on gender-affirming care for minors struck down as unconstitutional by a federal judge. 

In June, U.S. District Judge James Moody issued a permanent injunction against the first-in-the-nation ban, forbidding it from ever taking effect. Plaintiffs in the case prevailed on all three of their claims, with Moody finding that the prohibition: 

• Violated the Equal Protection Clause , as services like estrogen treatment and breast augmentation remain legal for minors so long as they aren’t being used to treat gender dysphoria.
• Infringed on parents’ due process rights to make decisions about their children’s medical care. 
• Flouted the First Amendment rights of doctors by barring them from referring their patients elsewhere for gender-affirming care. 

Yes, but: Last month, the full panel of 8th Circuit judges granted Arkansas Attorney General Tim Griffin ’s request to hear his appeal of Moody’s ruling. And while members of the appeals court in 2021 upheld a temporary hold on the law from Moody, Griffin, a Republican, is asking the judges to weigh the law under a more lenient standard this time around. 

In Tennessee and Kentucky 

The 6th Circuit ruled in late September that bans on transition care for youth in Tennessee and Kentucky can be enforced while lawsuits against them continue, lifting preliminary injunctions that had been granted by district courts. 

In its order, the appeals court dismissed a legal challenges filed against the restrictions, arguing that the laws don’t discriminate based on sex since the care being given would only apply to one group: transgender children. 

• Members of the panel cited the Supreme Court’s decision in the case that ended the federal right to abortion , wherein the justices concluded that restrictions on abortion are not discriminatory because they apply only to women. 

Supreme Court appeals

On our radar: Earlier this month, lawyers for families with transgender children in Kentucky and Tennessee asked the Supreme Court to review the 6th Circuit decision, arguing that the bans are unconstitutional because they violate equal protection and due process rights. 

The Biden administration has also asked the high court to weigh in . In a petition to the court this month, the Justice Department argued that any delay in its review of the case would endanger transgender youth who are or will be denied care that their doctors say is medically necessary. 

The move “significantly increases the likelihood traditionally” that the Supreme Court will take on a case, according to Eyer, who said it would be the first time that the justices have had to weigh in on such restrictions. 

“There is a concern generally about what this court would do with almost any issue on the political left,” Eyer said when asked how she thought the high court might rule in such a case. “But I think that part of the reason why the court has not been overly eager to take this up is that maybe it’s not even clear to the justices who have strong views about this about how it would turn out.”

In the courts

Virginia localities sue pharmaceutical giants over insulin costs.

New this a.m.: Three local governments in Virginia are suing pharmaceutical giants Eli Lilly , Novo Nordisk and Sanofi Aventis for allegedly conspiring with prescription drug middlemen to drive up the cost of insulin, The Washington Post’s Salvador Rizzo reports. 

The nearly identical lawsuits filed this month argue that thousands of Virginians who need the lifesaving drug to keep their diabetes in check have been harmed by “artificial” price increases engineered by the three insulin manufacturers and pharmacy benefit managers CVS Caremark , Express Scripts and OptumRx . All six companies are named as defendants in the suits.

The view from the industry: The insulin manufacturers dismissed the allegations and pointed to recent efforts to reduce insulin prices, including plans announced earlier this year by all three companies to cap out-of-pocket costs for the drug at $35 . A spokesman for CVS Caremark said insulin makers are responsible for setting prices for their medications. 

Zooming out: Other states and counties across the country, including California , Kansas , Minnesota and Mississippi , have filed similar legal complaints over insulin prices. A federal judge in New Jersey is overseeing a case combining more than a dozen such lawsuits by states and local governments.

Public health watch

How one rabid kitten triggered intensive effort to contain deadly virus.

My colleague Lena H. Sun is out with a deep dive into how a stray kitten in Nebraska mysteriously infected with a strain of raccoon rabies that had never been detected west of the Appalachian Mountains sparked a multiagency response from federal, state and local public health officials aimed at figuring out the origins of the deadly virus and curbing its spread. 

“We’ve never had a nine-alarm fire like this,” said Richard Chipman , the coordinator of the national rabies program at the Agriculture Department .

Why it matters: Rabies can result in enormous public health costs as pets and people are exposed. If the strain was left unchecked, the Centers for Disease Control and Prevention estimates it would have made its way to South Dakota , Minnesota , Iowa , Missouri and Kansas within five years, putting an estimated 7 million residents at increased risk for the lethal infection. 

You can read more about the emergency response effort involving trailers full of injectable rabies vaccines, gallons of anise oil and cases of marshmallows here .

Reproductive wars

Nevada judge strikes down proposed abortion rights ballot measure.

Advocates seeking to enshrine abortion rights in the Nevada Constitution are vowing to fight a judge’s decision rejecting their petition to put the issue before voters in the swing state next year. 

Key context: Last week, District Judge James T. Russell ruled that the proposed 2024 ballot initiative violates Nevada law by covering more than one subject. He also said the implications of the petition were unclear and that it has an unfunded mandate, according to local ABC affiliate KOLO News , which first reported the ruling. 

• If approved by voters, the proposed measure would have amended the state constitution to include the “fundamental right to reproductive freedom,” including prenatal care, childbirth, postpartum care, birth control, vasectomy, tubal ligation and abortion. 

On our radar: Lindsey Harmon , president of Nevadans for Reproductive Rights , which is behind the petition, said the political action committee plans to appeal the ruling. “We know that in fact, these are all a single subject,” she added. 

Harmon said the group prepared for potential court opposition . If the Nevada Supreme Court rules in their favor by January or February, she said supporters should still have enough time to collect more than 100,000 valid signatures in favor of the petition by early July — the cutoff for appearing on the statewide ballot in November 2024. 

📅 Welcome back! The House and Senate are both in session this week. 

Wednesday: A House Oversight and Accountability subcommittee will hold its second hearing on federal agencies’ post-pandemic telework policies; a House Energy and Commerce subcommittee will discuss how artificial intelligence is changing health care. 

Thursday: CDC Director Mandy Cohen will testify before a House Energy and Commerce subcommittee on how the agency is rebuilding public trust after the coronavirus pandemic. 

In other health news

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• Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy
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• http://orcid.org/0000-0003-2929-3831 Roberto D'Angelo
• The Institute of Contemporary Psychoanalysis , Los Angeles , California 90064 , USA
• Correspondence to Dr Roberto D'Angelo, The Institute of Contemporary Psychoanalysis, Los Angeles, CA 90064, USA; roberto{at}robertodangelo.com

Opinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth. Proponents claim that these treatments are well supported, while critics claim the poor-quality evidence base warrants extreme caution. Psychotherapy is one of the only available alternatives to the gender-affirming approach. Discussion of the treatment of gender dysphoria in young people is generally framed in terms of two binary approaches: affirmation or conversion. Psychotherapy/exploratory therapy offers a treatment option that lies outside this binary, although it is mistakenly conflated with conversion therapies. Psychotherapy does not impose restrictive gender stereotypes, as is sometimes claimed, but critically examines them. It empowers young people to develop creative solutions to their difficulties and promotes agency and autonomy. Importantly, an exploratory psychotherapeutic process can help to clarify whether gender dysphoria is a carrier for other psychological or social problems that may not be immediately apparent. Psychotherapy can therefore make a significant contribution to the optimal, ethical care of gender-dysphoric young people by ensuring that patients make appropriate, informed decisions about medical interventions which carry risks of harm and have a contested evidence base.

• Psychotherapy
• Gender Identity
• Mental Health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

http://dx.doi.org/10.1136/jme-2023-109282

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The treatment of gender dysphoria in children and adolescents is one of the most polarising and contested issues facing psychiatry today. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) articulates the central controversy in Position Statement 103, namely that ‘evidence and professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate’. 1 The recent Cass Review 2 and subsequent National Health Service (NHS) Interim Service Specification 3 highlight the uncertainty about whether gender-affirming medical interventions or psychosocial and mental health interventions (including exploratory psychotherapy) are most helpful and safe for young people experiencing gender dysphoria. The divergent views on how best to respond to young people with gender distress present clinical and ethical challenges for clinicians working in this area.

The evidence for gender-affirming interventions: opinion is divided

The gender-affirming approach, which involves various combinations of social transition (changes to appearance, names, pronouns, official documents, etc), endocrine treatment (puberty blockade and cross-sex hormones) and surgical interventions, has increasingly become the dominant treatment paradigm. 4 5 However, professional opinion is indeed divided regarding gender-affirming medical and surgical treatments for youth. 6 7 On the one hand, they have been widely supported by many professional medical organisations, particularly in the USA. 8–10 Proponents argue that gender-affirming interventions for youth are well established and safe treatments that have been shown to improve mental health outcomes and may even be life-saving. 11 12 They point to numerous studies reporting improvements in depression, anxiety and suicidal ideation in young people receiving medical interventions (see Coleman et al 5 for an overview of publications supporting gender-affirming interventions).

In contrast, European health authorities have conducted systematic reviews of studies examining the effectiveness and risks of medical interventions and have found that the evidence, including those studies reporting positive outcomes, was of very low quality and at high risk of bias, rendering any conclusions uncertain. 13–16 A rating of very low quality indicates that the true effect of the study intervention is likely to be substantially different from what the studies report. 17 18 Notably, the Swedish Health Authority concluded that the benefits of hormonal interventions for youth do not outweigh the risks at the population level. 15 Systematic reviews in Finland and the UK have led to significant revisions of official guidance on gender-affirming medical interventions, restricting their availability and limiting them to research settings. 3 19 Notably, the strong endorsement of gender-affirming medical interventions for youth by US medical bodies is not based on systematic reviews of their benefits.

Furthermore, critical analyses have cast doubt on whether the outcome data actually support claims that medical and surgical interventions result in substantial psychological benefits or reduced suicidality. 20 21 Some researchers have found that youth who had psychiatric problems before transition are no better off after transition and continue to struggle with these problems. 22 Notably, apart from a single case report, 23 no long-term studies have evaluated the physical and mental health outcomes of adolescents who have undergone gender-affirming interventions beyond very early adulthood. While influential organisations warn that delaying gender-affirming medical treatments is harmful to young people, 5 9 there is no longitudinal evidence to support this claim. The only prospective study comparing a treated and untreated group of gender-dysphoric adolescents found no difference in psychosocial functioning between those receiving puberty blockers and psychosocial support, and a comparison group receiving only psychosocial support. 24 Another study found that the majority of adolescents who were denied gender reassignment chose not to pursue gender transition as adults. 25 Studies which raise question about the benefits of gender-affirming interventions, however, are also of poor quality, as are all studies included in the National Institute for Health and Care Excellence reviews. 13 14

Puberty blockers, once thought to be fully reversible, are now known to have significant impacts on bone density 26–28 and, when followed by cross-sex hormones, are likely to cause infertility. 29 There are also questions about whether they affect brain development. 2 14 In particular, while puberty blockers are often understood to provide a ‘pause’, 23 allowing the young person time to explore their gender and consider future treatment, virtually all children who start puberty blockade progress to cross-sex hormones. 30–33 Cross-sex hormones cause irreversible cosmetic changes such as deepening of the voice, breast growth and balding. Long-term hormone therapy has long been known to increase the risk of cardiovascular disease, stroke and cancer, leading to a black box warning for these drugs in the USA. 34 35 Gender-affirming surgeries are irreversible and entail significant risks, including loss of sexual function, infertility, fistula, urinary incontinence or stenosis, numbness or chronic pain, 36 37 and even death. 38

The polarised appraisals of the outcome literature regarding the efficacy and safety of medical interventions are at the heart of the dilemma articulated by the RANZCP. Healthcare practices and policies in relation to youth with gender distress vary widely, depending on how clinicians and policymakers evaluate the research. In the USA and Australia, many states are working towards easier access to medical intervention, with some introducing models of care for adolescents over the age of 16 years that no longer require any evaluation or even parental support. 39 At the same time, an increasing number of states are introducing legislative bans on gender-affirming medical interventions for minors. 40 In Europe, a growing number of countries, including the UK, Finland and Sweden, have sharply curtailed medical interventions for trans-identifying youth and now recommend psychosocial interventions as first line. 3 15 41 42 Given the absence of long-term follow-up studies and the low quality of the evidence base, it is impossible to know which approach is most likely to achieve long-term resolution of gender dysphoria, improved functioning and better mental health outcomes while minimising the risk of iatrogenic harm.

Psychotherapy: the evidence

One of the only available alternative approaches to the highly medicalised affirmative model of care for gender dysphoria in youth is psychotherapy. However, the evidence supporting psychotherapy for gender dysphoria is even more limited than that for medical treatments, consisting primarily of case reports and small case series (eg, 43–50 ). Nevertheless, despite the limited evidence for their efficacy for gender dysphoria, individual and family psychological interventions, including psychodynamic, cognitive–behavioural and systemic approaches, are generally considered safe and are the established foundations of child and adolescent mental healthcare. 51 52 They have been helpfully applied to diverse forms of psychological distress, including conditions associated with distress about the body and identity problems, suggesting their applicability and likely helpfulness for patients experiencing gender distress. Importantly, a substantial evidence base supports the efficacy of psychodynamic psychotherapy for a wide range of conditions, 53–58 including those affecting children and adolescents. 59 Furthermore, researchers highlight that psychotherapy can be considered ‘transdiagnostic’ rather than diagnosis specific, making it applicable to a range of emotional disorders. 54 Importantly, while numerous potential harms of gender-affirming interventions have been established, there is no evidence that appropriate, non-pathologising psychotherapy causes harm to trans-identified youth.

Consideration of psychotherapy as a first-line treatment for gender dysphoria consistently raises concerns about the potential harms of delaying medical intervention and allowing a young person to go through an unwanted puberty. 60 61 As with most other research in this area, the evidence to support this concern is of low quality. For example, a cross-sectional study found an association between puberty blockade and reduced suicidality, but the study, which was based on a convenience sample, could not determine the direction of causality. 62 And in a sample of teens with gender dysphoria, those who presented at an older age had poorer mental health than those who presented at a younger age. 63 While this may suggest that early medical treatment is beneficial, as the study authors claim, this study also could not prove causality. An equally likely hypothesis is that these studies indicate that young people with later-onset gender dysphoria have more mental health problems, a phenomenon reported by researchers across the western world. 64 65 Dutch researchers have warned that the recent unprecedented increase in adolescent-onset gender dysphoria represents a change in the presentation of this condition. These researchers have raised questions about whether the positive outcomes they observed in the early-onset group will apply to young people with adolescent-onset gender dysphoria, who now make up the vast majority of child and adolescent referrals. 66

This presents clinicians with an ethical dilemma in which they have no reliable data with which to weigh up the potential impact of delaying medical interventions, with the risks of these treatments, and the potential benefits or risks of providing psychotherapy instead of medical intervention. There is a notable absence of research literature comparing psychological interventions with gender-affirming interventions for young people with gender dysphoria. One small study comparing adolescents treated with puberty blockade with those receiving psychotherapy alone found that there was no significant difference between the two groups at the study endpoint. 24 There is an urgent need for robust research to assess the benefits and any possible risks of psychotherapy in this patient group, as well as reliable research to investigate the impact of delaying medical intervention.

The conflation of psychotherapy with conversion therapy

Gender dysphoria in both adults and minors encompasses a range of experiences involving distress about and preoccupation with one’s natal sex, particularly the sexed body, and with the gender roles associated with that sex. Individuals commonly report distress over a sense of incongruence between their experienced gender and their natal sex. The focus on incongruence as the central problem has shaped public and clinical discourses, leading to an assumption that there are only two possible approaches to treatment, each of which attempts to address the experience of incongruence in different ways. The first is the gender-affirming approach, which provides social, medical and surgical interventions to alter the body/appearance so that it is experienced as more aligned with the individual’s experienced gender. 5 67 The second approach to incongruence seeks to change the subjective experience of gender by aligning the mind with the body. It aims to help the person to accept their sexed body as it is and to live as the gender they were assigned at birth. Some claim that this approach is a form of ‘conversion therapy’. 68–70

The term ‘conversion therapy’ was originally coined to describe interventions designed to make same-sex attracted people heterosexual, using psychological, behavioural, aversive or faith-based approaches. These interventions are now considered to be both ineffective and harmful. 71 In the UK, gay conversion therapy consisted mainly of aversion therapy. 72 There are no data to determine how common the other forms of conversion therapy were. It is important to note that trans-sexuals, as they were known at the time, were never routinely offered aversion therapy—instead, the clinical response involved determining whether the patient was suitable for medical gender reassignment. 72 Conversion therapy is now illegal in several states in Australia, 73 the USA, 61 and an increasing number of countries worldwide have bans in place or are working to introduce them, including the UK. Statements and bans on conversion therapy usually problematically merge gender identity with sexual orientation, which is misleading as these are very different constructs. 72 74 Further, the appropriateness of grouping aversive and other conversion techniques applied to gay adults in the past with exploratory therapy for gender-distressed youth today is highly questionable. 72 74

In the mid-20th century, many psychoanalytic practitioners, in both the USA and the UK, believed that homosexual behaviour was pathological, arguing that it was a perversion or developmental fixation, or that it was driven by phobic avoidance or neurotic conflict. 75 76 Gay men and lesbians were excluded from training in American Psychoanalytic Association institutions until 1991 75 and from British analytical training programmes until the early 2000s. 76 Influential psychoanalytic writings from the 1960s to the 1980s recommended that analysts should take a directive stance in working with patients and actively discourage homosexual behaviour. 77 It is not clear for how long or to what extent this ‘directive-suggestive’ approach was representative of the way most analysts actually practised at the time, 77 78 but most psychoanalytic writing about homosexuality in the 20th century was unequivocally pathologising. 75 76 79 The psychoanalytic view that homosexuality should be treated was not based on science but was a collusion with the widespread xenophobia and conservatism of the time. 79 Psychoanalysis ignored the emerging science being produced by sexologists such as Kinsey, which demonstrated that homosexuality was not pathological. 75 Thankfully, psychoanalytic theory and practice have changed dramatically since then, and most contemporary psychotherapists and psychoanalysts would agree that attempts to direct or coerce change in an individual’s sexual orientation or gender identity have no place in healthcare. However, the unfortunate legacy of this era is that psychotherapy and psychoanalysis are now viewed with suspicion when applied to sexuality and gender-diverse individuals.

Against this background, psychotherapy has become increasingly controversial as an appropriate approach to gender dysphoria in young people. Critics of psychotherapeutic work with gender dysphoria argue that it aims for a ‘cisgender’ outcome, particularly when it explores whether gender distress is secondary to other issues. 80–82 This assertion is based on a mistaken assumption about the purpose of psychotherapy and is evidence of the continuing effects of psychoanalysis’ troubled history with regard to homosexuality. The conflation of psychotherapy with conversion therapy is arguably also a consequence of the pervasive binary 83 within which affirmation or conversion have become the only available ways of conceptualising responses to trans-identified youth. This conflation is evident in a statement from the Australian Professional Association for Transgender Health (AusPATH): ‘The AusPATH Board do not support ‘exploratory therapy’ which is often used as a euphemism for conversion therapy’. 84 It is also promoted by in publications written by advocates of medical transition, claiming that gender-exploratory psychotherapy and conversion therapy share many conceptual similarities. 82 85

In the rapidly evolving and heated political climate surrounding healthcare for trans youth, clinicians may assume that anything other than the gender-affirming approach, particularly psychotherapy, is ‘conversion therapy’. 86 87 This is also fuelled by conversion therapy laws, which are often unclear as to whether exploring rather than immediately affirming constitutes conversion therapy. 86 88 89 Some conversion therapy bans are so broad that they potentially put clinicians at risk of prosecution for providing exploratory psychotherapy. 86 In response to this conflation, the British Psychoanalytic Council has expressed concern that exploratory therapies may be outlawed by conversion therapy bans. 90 This has far-reaching implications for psychiatric practice, as exploratory therapy is synonymous with psychodynamic psychotherapy, 91 a treatment modality endorsed by the Royal College of Psychiatrists 92 and the RANZCP. 57

To suggest that psychotherapy is a form of conversion therapy betrays a fundamental misunderstanding of psychotherapy. Psychotherapy resides outside the affirmation-conversion binary and aims to address the distress of gender-dysphoric youth rather than to correct a sense of misalignment . Psychotherapy does not attempt to force change or impose any predetermined notion of ‘cure’ or preferred gender or sexual orientation on the patient. A core ethical principle of psychotherapy is that therapists must respect patient autonomy and self-determination 93 and refrain from any attempt to influence the patient. A priori assumptions, either that trans identification is always a healthy development or that trans identification is always pathological, violate this foundational principle. A genuine psychotherapeutic process starts from a position of not knowing and seeks to open things up. Anything else is a misuse of psychotherapy. Mitchell, one of the most prominent voices in late 20th-century American psychoanalysis, made this clear four decades ago when he warned that a ‘directive-suggestive’ approach to homosexuality contravenes ‘several fundamental principles of sound psychoanalytic practice’. 77 The same is true of therapeutic work with gender dysphoria.

Psychotherapy supports autonomy

The gender-affirming approach holds that patient autonomy is best protected when we allow the young person to take the lead in making decisions about treatment and transition. 4 Psychotherapy is also a patient-led process that privileges autonomy. However, psychotherapists believe that the best way to support autonomy is to help patients to know themselves, including how their current experience has been shaped by past and present relational and contextual factors, some of which may be beyond their awareness. Psychotherapy is a collaborative process of curiosity and exploration that helps individuals locate and illuminate the origins of their distress so that durable, meaningful solutions can be generated. Psychotherapists working at depth with trans youth often find that gender issues are nested within complicated psychosocial, family and/or developmental issues or that trans identification is a proxy or carrier for other difficulties. 45 94–99 Experienced psychotherapists know that the traumatic or developmental origins of emotional distress often only become apparent after many, many months of careful exploratory work. Dealing with these issues sometimes dramatically alters self-experience in a broad range of ways, including the experience of gender dysphoria. 43–50 This cannot occur without a detailed inquiry that questions and explores the patient’s presenting difficulties and convictions. Unquestioning affirmation is in itself a form of influence that forecloses a thoroughgoing exploration and potentially compromises autonomy.

But here is the rub: is this not a repetition of that problematic era in our history when homosexuality was thought to be a manifestation of psychopathology, developmental arrest or unconscious conflict? This would be the case if the intention was to impose a preferred, normative outcome on the patient, as some 20th-century psychoanalysts did with gay and lesbian patients. To be clear: using psychotherapy to impose a moral bias against gender diversity or gender non-conformity is a perversion of the psychotherapeutic process . However, there is a significant difference between homosexuality and trans identification. Transgender identification sometimes involves invasive, irreversible body alterations with uncertain long-term benefits and known risks, 15 16 30 81 82 so the stakes are much higher than for young people exploring their sexual orientation. A person whose sexual orientation changes at some point in the future is in a very different position to a person whose gender identity changes after undergoing irreversible gender-affirming treatments, which they may regret and feel damaged by. The growing number of online testimonials from detransitioners 1 illustrates the potential adverse outcomes that can occur. While detransition and regret were previously thought to be vanishingly rare, emerging evidence suggests that it may be a much more common outcome. 100–102 Recent publications indicate that up to 30% of people who start hormone therapy as minors will discontinue within a few years. 103–106 By this time, they will already have undergone irreversible physical changes. Although not all patients who detransition or discontinue treatment will experience regret, it is likely that many will. Most clinicians would agree that such adverse outcomes should be avoided and this is where psychotherapy can make a crucial contribution.

Psychotherapy empowers gender-distressed youth to make truly informed choices about their lives. By helping patients gain greater clarity about the sources of their distress, which are often more complex than initially thought, they will then be in the best position to determine whether gender-affirming interventions will bring the benefits they hope for, whether they may do more harm than good or whether the solution lies elsewhere. Psychotherapy can make a crucial contribution to this process by helping patients to consider whether trans identification will be liberating and growth promoting or whether it is a carrier for other previously unaddressed or even unacknowledged difficulties. Recent publications suggest that most detransitioners feel they did not receive adequate exploration, with most subsequently realising that their gender dysphoria was not simply a matter of identity or gender diversity as they initially thought. 107 Many came to understand that their gender distress was secondary to other issues, such as mental health conditions, trauma, internalised homophobia or internalised misogyny. 108

When gender dysphoria is a manifestation of other issues

A 2021 report on conversion therapy commissioned by the UK government specifically identifies talking therapies as a common form of conversion therapy. 109 The report claims that mental health professionals who treat minority gender identities as symptoms of mental illness may be practising conversion therapy. On the other hand, the NHS has recently emphasised that gender dysphoria may in fact be secondary to other difficulties . The recent Interim Service Specification states that gender incongruence may be related to mental health problems, neurodevelopmental issues, or family and psychosocial complexities in ways that ‘may not be readily apparent and will require careful exploration’. 3 These conflicting positions reflect the central debate in the field, which lies at the heart of uncertainty about whether gender-affirming treatments or psychological interventions are most appropriate. Opinion is divided as to whether clinicians should explore whether a patient’s trans identification is a manifestation of other difficulties or whether they should accept trans identities at face value as a normal variation of human gender. However, even Diane Ehrensaft, an influential gender clinician and vocal proponent for the ‘normal variation’ perspective and the gender affirming approach 67 acknowledges that psychotherapists ‘have the tools to decipher whether a child’s gender expansive articulations could possibly be a solution to or a symptom of another life problem or underlying psychiatric issue’. 110

If we accept that some people will be helped by transition and some will not, then the most important ethical responsibility for clinicians is to explore whether gender dysphoria is a manifestation of another problem. As the NHS has noted, these problems are not always easy to identify, suggesting that inadequate exploration increases the risk that they may be missed, leading to misdiagnosis. As a result, patients may not receive appropriate and necessary interventions that comprehensively address their difficulties, leaving their core issues unaddressed and untreated. 107 Furthermore, failure to explore exposes these patients to interventions that will ultimately be unhelpful and carry a significant risk of iatrogenic harm. Indeed, the psychotherapeutic ‘deep dive’ into the child’s or young person’s experience recommended by Ehrensaft is arguably essential to ensure safe, informed and effective care for gender-distressed youth. The reality is that many, if not most, young people are not offered the opportunity to engage in self-reflection with the support of a qualified clinician in order to understand themselves more deeply before undergoing medical gender transition. Assessments for medical interventions are often brief, taking place over only a handful of sessions, and are often based on the belief that the young person’s self-identified gender should be affirmed. 87 111 112 The USA is increasingly moving towards a model of care for people over 18 years that no longer requires any psychological assessment prior to initiating treatment. This approach is also recommended for adolescents, 113 and clinics that operate according to this model offer to prescribe hormones on the first or second visit for young people aged 16 years and over. 39

This trend is arguably a consequence of a perspective that views trans identity not just as a normal variation but as an intrinsic, even constitutional aspect of human experience. If we accept this reification of gender identity, detailed psychological exploration is misguided and unnecessary. Contemporary theorists present a more fluid view of gender identity development, arguing that it is an emergent phenomenon that arises at the intersection of multiple interacting systems. 96 Gender is ‘softly assembled’, evolving in a non-linear fashion, and shaped by the current context and the individual’s relational and developmental history. 114 This model of gender, based on complexity theory, asserts that small shifts in component subsystems can lead to large, unexpected and unpredictable changes. This applies to psychotherapy, which can result in significant shifts in self-experience that cannot be predicted at the outset. In addition to elucidating the idiosyncratic shaping of each person’s gendered experience, psychotherapeutic exploration can also be a catalyst for further growth, evolution and change. How we respond to gender-distressed youth is therefore profoundly shaped by whether gender is conceptualised as a reified property of the individual or as ‘softly assembled’. This raises important questions about how best to facilitate the non-linear development of gender without prematurely foreclosing possibilities.

Psychotherapy and informed consent

Informed consent for gender-affirming interventions in young people presents particular ethical dilemmas for clinicians. Young people, their families and clinicians are faced with decisions about treatments with uncertain long-term risks and benefits. 115 Furthermore, the age at which adolescents are considered developmentally capable to provide informed consent or assent varies and remains controversial. Specifically, in the context of gender-affirming care, younger patients may not understand the full range of possibilities of living as a gender non-conforming or queer person, or the sexuality options available to them. 115 They are also unlikely to appreciate the importance of fertility preservation as evidenced by the very low uptake of fertility preservation among trans-identified youth. 116 In addition, young patients seeking relief from distress may not understand or may disavow the potential seriousness of long-term adverse effects, such as bone loss, heart disease and loss of sexual function. The consent process is further complicated by differing opinions about the adequacy of the evidence base for gender-affirming medical treatments and emerging rates of detransition, which require balanced discussion and reflection. 111 The Cass Review highlighted this issue, finding that patients, families and carers did not have adequate access to accurate and balanced information to make informed treatment decisions. 2

Most importantly, for the purposes of this paper, the fact that gender dysphoria may be related to other psychosocial problems in ways that are not initially apparent to the patient, clinician or family is crucial to the informed consent process. Informed consent is seriously compromised if the patient and clinician have an inaccurate or incomplete understanding of the cause of the patient’s distress or problem. Currently, we have no screening tools or protocols to determine in which individuals’ gender dysphoria is a carrier for another psychosocial or mental health issue. Similarly, we have no reliable way of predicting which young people will be helped by transition and which will not. The best, and arguably only, tool we have is detailed psychotherapeutic exploration that extends over a long enough period to allow significant, previously unknown or unconscious issues to become available for reflection. To make an informed decision, we need to have all the facts. This arguably includes those facts that are not ‘readily apparent’ 3 or outside awareness. If we accept that some of the factors that shape individuals’ decisions about medical transition are not conscious and take time to access, then robust informed decision-making is not possible without a detailed psychotherapeutic process that attempts to open up previously unacknowledged difficulties or areas of experience. 98 Sensitive psychotherapeutic exploration is not about paternalism or gatekeeping. On the contrary, it protects autonomy by providing a space for careful, nuanced reflection in which complex, shared decision-making is encouraged and facilitated.

Psychotherapy and gender normativity

Finally, critics who claim that exploratory psychotherapy is conversion therapy argue that it imposes gender normativity on the patient. 68 80 82 This is a misrepresentation of contemporary psychotherapeutic practice. Psychotherapy has evolved dramatically in recent decades, interrogating its earlier normative assumptions, exploring sociopolitical influences on mental life, and addressing homophobia, misogyny, and the social construction of gender. An essential aspect of psychotherapeutic work with young people with gender dysphoria is to explore the specific, idiosyncratic meanings associated with the unwanted gender and the desired gender and how regressive ideas about gender may underpin them. Psychotherapy provides a space in which patient and therapist can question the assumptions and regulatory discourses that underpin why certain qualities, behaviours, identities and sensibilities are associated with particular body configurations, types of dress, gender signifiers, etc. They may question whether transition is truly gender expansive or whether it perpetuates those very norms that the young person finds oppressive. Thinking critically about these gender norms invites young people to generate heretofore unimagined ways of embracing gender diversity that are arguably safer than gender-affirming interventions.

To suggest that exploratory therapy or psychotherapy for gender dysphoria is de facto conversion therapy is to mischaracterise psychotherapy as a process that seeks to impose gender conformity and normative sexuality on the patient. This misunderstanding is a consequence of the mid-20th century psychotherapeutic approach to homosexuality, which was pathologising, morally driven and ignored the science . In contrast, the rationale for psychotherapy for young people with gender dysphoria emerges from a careful appraisal of the science highlighting the uncertainties and risks of gender-affirming treatments. The inclusion of psychotherapeutic exploration in the response to young people with gender distress is not based on a moral imperative but on an ethical one. Any intervention, including psychotherapy, can be misused to exert undue influence and impose a preferred outcome. Public and clinical discourses that emphasise the misuse of psychotherapy over the wide-ranging benefits of a rigorous psychotherapeutic process effectively throw the unjustly demonised baby out with the bathwater. Importantly, for gender-distressed youth and their families, this mischaracterisation creates a barrier to accessing a valuable therapeutic modality that supports autonomy, gender diversity, the provision of appropriate care and fully informed consent.

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• Hopwood R ,
• Kimberly LL ,
• Folkers KM ,
• Friesen P , et al
• Tishelman AC ,
• Caltabellotta NM , et al

Contributors RD'A was responsible for the overall content as the guarantor.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests RD'A is a board member of the Society for Evidence-based Gender Medicine and a member of the advisory board for the Gender Exploratory Therapy Association.

Provenance and peer review Not commissioned; externally peer reviewed.

↵ ‘Detransition’ refers to stopping or reversing a transition and can involve social and legal changes, discontinuation of endocrine medications, surgical intervention to reverse the effects of transition or varying combinations of the above. 100

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