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Gender Dysphoria: Bioethical Aspects of Medical Treatment

Marta r bizic, milos jeftovic, slavica pusica, borko stojanovic, dragana duisin, svetlana vujovic, vojin rakic, miroslav l djordjevic.

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Academic Editor: Joseph F. Buell

Corresponding author.

Received 2018 Jan 11; Accepted 2018 Mar 26; Collection date 2018.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

1. Introduction

Gender dysphoria (GD) represents a condition where a person's gender assigned at birth and the gender with which they identify themselves are incongruent. Hence, these individuals can be very uncomfortable with their biological sex, primary and secondary sex characteristics, and social gender roles and they experience various levels of distress. Presence of public figures who are openly transgender, their appearance in mainstream media, and political and social climate lead to more individuals coming out in the open as to their state. Prevalence rate cannot be correctly estimated considering that people are still hesitant to come forward to health centers. According to DSM-5, the prevalence of gender dysphoria is 0.005-0.014% for adult natal males and 0.002-0.003% for adult natal females [ 1 ].

In accordance with their wishes, individuals with this condition can choose the direction in which their transition will proceed. To take the edge off their state, one can choose to go through a social transition. The social transition includes using a different name, pronouns, transformation of physical appearance, use of suitable bathrooms, and taking social roles of the affirmed gender. A more radical approach is the medical transition that includes hormonal and surgical treatment. Medical treatment requires a team of experienced experts, and it usually includes mental health professionals, endocrinologists, and surgeons. Psychiatric assessment is the first step and is very complex because it is necessary to exclude other conditions that might mimic gender dysphoria. The next step is hormonal treatment, under the care of an endocrinologist, which is then followed by “a real-life trial.” Some individuals decide to stop here, while others continue to gender-affirming surgery (GAS). The seventh edition of the Standards of Care of the World Professional Association of Transgender Health (WPATH) offers flexible guidelines for the treatment of people experiencing gender dysphoria and describes the criteria for surgical treatment [ 2 ]. Patients undergoing GAS of their choice are required to provide two recommendation letters from certified psychiatrists and a gender specialist, as well as a confirmation of having been on hormonal therapy prescribed by an endocrinologist for a period of a minimum of one year. Gender affirmation surgery refers to all surgical procedures that a patient wishes to undergo in an attempt to become as similar as possible to the desired gender.

Treatment of gender dysphoria always raised numerous ethical issues, and with rapid acknowledgment and recent achievements, new complex issues in medical management have emerged. With unknown etiology and questionable definition (mental/medical illness, social construct, and variation of sex) who can decide, with 100% certainty, what treatment is in the best interest of a particular patient? The most prominent challenges and ethical questions pertain to the treatment of underage individuals, fertility after GAS, and possibility of regret after GAS. Main ethical principles are autonomy, beneficence, nonmaleficence, and informed consent. The individual must have autonomy of thought and intention when making decisions about medical treatment. This is an especially sensitive field in treatment of gender dysphoria, because sometimes the individual's desires, hopes, and expectations might not correlate with reality. Experts must be very straightforward regarding specific possibilities, risks, and benefits of medical treatment, especially considering that the last step in medical transition, GAS, is irreversible. Beneficence implies doing only good, only what is in the patient's best interest. However, some may consider that surgical alteration of healthy organs, in case of GAS, is not in line with this principle. Nonmaleficence must ensure that the treatment does not harm the individual in an emotional, social, or physical sense. Always keeping these principles in mind, WPATH Standards of Care and criteria for diagnosis might not be enough to be ascertain that we are doing the right thing. Although it may seem that an individual fulfills all these criteria on paper, sometimes we can observe their personal disadvantages, youth, impairment, or desperation. It seems that, even with the reassurance and recommendation from a mental health professional, ethical unease cannot be entirely erased because treatment guidelines have preceded the answers to vitally relevant questions [ 3 , 4 ].

2. Transgender Youth

Children represent a small number of individuals with gender dysphoria and in only 10-20% of the children, gender dysphoria will continue to manifest in adolescence [ 5 ]. However, psychological therapy and support are highly recommended; while such services are now far more widely available, they are still insufficient to provide for complete wellbeing of these patients. Inadequate management of children with persistent gender dysphoria can lead to isolation, feeling of self-hatred, and suicidal ideas and attempts. Also, “passing through the wrong puberty” can have serious consequences for these individuals. Viable treatment options vary from fully reversible treatment, such as puberty-suppressing gonadotropin-releasing hormone analogues (GnRH) to partly reversible treatment, gonadal steroid treatment, as well as irreversible treatment, such as surgical removal of genitalia and reconstruction of new ones according to the desired gender. Surgery includes bilateral mastectomy with chest reconstruction, hysterectomy with oophorectomy followed by either metoidioplasty or phalloplasty for trans-male individuals, and bilateral orchiectomy with penectomy followed by vulvoplasty and vaginoplasty in trans-female individuals [ 6 ].

Pubertal suppression is implemented using GnRH analogues at Tanner 2 or 3 stage of puberty. Hypothalamus produces GnRH at low levels in prepubertal children. Levels become cyclical during puberty, leading to the production of luteinizing hormone (LH) and follicle stimulating hormone (FSH) by the anterior pituitary. LH and FSH stimulate ovaries and testicles to produce sex hormones, estrogen and testosterone, which are responsible for stimulating the growth of genitalia. Also, they lead to the development of breasts, voice deepening, menstrual cycle, and so forth, which transgender youth can find particularly tough to handle [ 7 ].

There are only a few reports related to the use of GnRH analogues in transgender youth. De Vries et al. were the first to introduce the concept and research on the use of puberty blockers for treatment of transgender youth. The main idea behind the suppression of endogenous puberty was to decrease distress by preventing the development of “noncongruent” secondary sexual characteristics. This would give young individuals more time to get accustomed to their situation and to better explore their gender. In the examined group, all of 70 eligible candidates showed improved mental health and general functioning. Authors concluded that the treatment was fully reversible, which was one of its main advantages [ 8 ]. Despite the positive outcomes in puberty suppression, many experts still have concerns and resist the implementation of this treatment in their regular practice. Viner et al. proposed that GnRH therapy can be physically damaging for teenagers and can lead to unfavorable psychological consequences [ 9 ]. Olson-Kennedy et al. also recognized these dilemmas, stating that available data on puberty suppression was limited and many questions remained unanswered [ 10 ]. One of the main reasons against this treatment is that going through puberty may help the individual to become congruent with their biological sex, meaning that their GD would not persist into adolescence. Results from Steensma et al. showed that majority of children developed homosexual orientation after completion of the GnRH treatment [ 11 ]. As for potential consequences, Hembree recently reported no long-term consequences in follow-up studies of GnRH treatment [ 12 ].

Finally, the decision about implementing GnRH treatment is very difficult and cannot be made without ethical dilemmas. Both opponents and advocates of pubertal suppression are guided by the same ethical principles, beneficence, nonmaleficence, and autonomy, but have different views on where these principles lead. A unique and clear overview is necessary, and, to this day, it has not yet been elaborated. Considering that GnRH treatment is relatively new and controversial, additional qualitative research and empirical studies are necessary for appropriate bioethical definitions.

Transgender persons require safe and effective hormonal support to develop the physical characteristics that affirm their gender identity. The main indications for the beginning of hormonal therapy are confirmed persistence of gender dysphoria and adequate mental capacity to give informed consent and accept this partially irreversible treatment. According to the most recent Endocrine Society guidelines, most adolescents develop this capacity by the age of 16 [ 12 ]. Also, Hembree et al. recognized some compelling reasons to initiate sex hormonal therapy before 16, but there is little data published on the experiences with this treatment prior to 14 years of age [ 12 ]. The main goals of cross-sex hormonal therapy are suppression of endogenous sex hormone secretion, determined by the person's genetic/gonadal sex, and maintaining sex hormone levels within the normal range for the person's affirmed gender. This therapy harmonizes the external appearance with affirmed gender, leading to, in transgender men, male-sounding voice, different fat distribution, increase in muscle mass and, in transgender women, breast growth, decreased facial and body hair, more feminine fat redistribution, and decreased muscle mass [ 12 ].

Many studies demonstrated long-term safety and high efficiency of hormonal therapy in transgender adults. For trans-women, Asscheman et al. emphasized a warning to a side effect of particular concern, estrogen-induced hypercoagulability and subsequent venous thromboembolism. Hembree addressed some potential adverse physical effects of testosterone treatment, such as polycythemia vera and dyslipidemia, in transgender men. Generally, a majority of the authors concluded that this therapy was safe, with necessary follow-up for potential complications [ 12 – 14 ]. However, only a few studies looked into the impact of cross-sex hormonal therapy on transgender youth. Jarin et al. performed a retrospective study on 116 adolescents aged 14–25 years with gender dysphoria and have reported minimal impact of hormone treatment. In trans-men, the only findings were an increase in hemoglobin, hematocrit, and body mass index with lowering of high-density lipoprotein levels; in trans-women, only lower testosterone and alanine aminotransferase (ALT) were reported [ 15 ]. Olson-Kennedy et al., in their prospective study, found several statistically significant changes in mean values of physiological parameters over time but of no consequence to clinical safety concerns [ 16 ]. In both studies, the authors indicated that this cross-sex hormonal therapy is safe for transgender youth over a period of approximately two years. However, the strongest argument against cross-sex therapy lies in the lack of knowledge of its long-term effects, which means that more studies and follow-up information are necessary. One of the questions is a possibility for cross-sex hormonal therapy in individuals below 16 years of age. The authors of the latest guidelines of the Endocrine Society recognized this possibility but only on a “case by case” principle, meaning that age does not always accurately reflect one's readiness for medical interventions. Also, some experts noticed that a clear majority of children on GnRH therapy will decide to pursue cross-sex hormonal therapy. Only a few side effects of using GnRH were observed, such as decreased bone density [ 17 ].

Based on bioethical principles, children usually do not have the power to make legal decisions and actions at the initiation of cross-hormonal therapy. Nevertheless, their judgment and opinions should not be disregarded. Cross-sex therapy primarily helps individuals with GD to harmonize their external appearance with their experienced gender. In this case, proper education of the patient and pointing out advantages and shortcomings of such treatment are of crucial importance. Following the principle of beneficence, clinicians are always obliged to help the person and to follow the prescribed hormonal treatment, since there are no better options at this moment. Patients who are denied treatment can develop serious psychological consequences. Generally, the transgender population is at higher risk of self-harm and suicide [ 18 ]. A more individualized approach, as in the “case by case” system, will ensure that a right decision is made in accordance with the patient's maturity, age, and judgment.

Gender affirmation surgery is the last step in the medical transition. It is considered to be irreversible and is technically demanding to perform, even for experienced surgeons. According to WPATH Standards of Care, a criterion for eligibility for GAS is “reached legal age of maturity in a given country.” Presumably, the threshold is 18 years of age in most countries [ 19 ]. The increasing usage of puberty blockers and pushing the limits for the start of the cross-sex hormone therapy lead to further problems and dilemmas. With these developments, it was only a matter of time before the issue of GAS in minors would arise. Viewpoints are different and vary between the beneficence principle embodied in the motto “doing nothing is doing harm” and the nonmaleficence variation of “the treatment plan that involves less extensive surgery or none at all,” reported by Cohen-Kettenis and Holman, respectively [ 20 , 21 ].

Changing the legislation for hormonal therapy without GAS increases the gap between the two medical procedures and postpones the desired outcome of the transition. During this interim period, someone living with atypical genitalia can easily be exposed in public and lose control over something that used to be very private [ 22 ]. Transgender community is more often targeted by bullying and has higher rates of suicide. Leaving these patients to wait for the final stage in their transition can have an impact on their social and psychological state. Goffman's theory of stigma postulates that the transitioning adolescents must prove their affirmed gender to others [ 23 ]. If others question the individual's gender identity, including the presence of gender-congruent genitals, he or she fails to manage the stigma and becomes “discredited.” In addition, postponing romantic relationships and dating until the age of 18 can also lead to psychological struggles and challenges.

On the other hand, the main “technical” issue in case of children treated with puberty blockers lies in their undeveloped genitalia. Thus, the GAS will be more troublesome, especially in case of penile inversion vaginoplasty. Some authors reported autologous skin grafting from donor site or use of bowel segments as viable solutions for this issue [ 24 , 25 ]. However, the main concern is the possibility of regret after the GAS. As already mentioned in Introduction, GD does not persist through adolescence in the vast majority of children. The results of GAS in transgender minors and their possible regret are a great cause of concern and a huge responsibility for medical professionals [ 26 ]. The dilemmas remain: is it better to suffer the consequences of GD or GAS? Are children or teenagers mature enough to make these kinds of decisions? Further research and data are necessary to resolve these crucial dilemmas.

3. Fertility

Treatment of GD enables the individuals to continue their life in their affirmed gender. For some transgender individuals, this implies the same as for cisgender persons, marriage or/and children. Members of the transgender population have the same desire for offspring, for the same reasons as the cisgender population, and fertility presents one of the most delicate issues. Infertility in trans-women is caused by orchiectomy as a part of the GAS. Conversely, hysterectomy and oophorectomy eliminate the chance of pregnancy in trans-men. Cross-sex hormonal therapy also has an impact on fertility, but such treatment is not a definitive cause of infertility, due to the possibility of reversal. Three decades ago, Payer described that estrogen in trans-women leads to the reduction of testicular volume and has a strong suppressive effect on sperm motility and density [ 27 ]. Testosterone therapy for trans-men leads to reversible amenorrhea according to Van Den Broecke's study in 2001 [ 28 ]. Patients are usually at full reproductive age at the initiation of their transition and a clear majority of them express the desire for reproductive potential after transition [ 29 , 30 ]. This is almost impossible, as irreversible transition means losing the option for having children. Dunne reviewed sterilization requirements for transgender people in Europe and found sterilization as the only possible option in 20 European countries; this means that any chance for biological offspring is lost with this transition [ 31 ]. This discrimination deeply undermines the fundamental bioethics law, and societies such as WPATH and the Endocrine Society advocate for counseling and detailed explanation of the consequences of treatment and viable options for fertility preservation. In addition, the possibility of sterility following the use of puberty blockers and cross-sex hormones gives rise to further controversy and ethical dilemmas, as do options of cryopreservation prior to the start of cross-sex hormonal therapy and uterus transplantation for trans-women.

As we have previously mentioned, puberty blockers are considered to be the reversible part of the transition, preventing secondary sex characteristics from developing. However, some authors confirmed that these blockers also have an impact on maturation of germ cells, which could be used for preservation of the biological fertility potential [ 32 ]. Individuals on puberty suppression therapy may show an interest in offspring but, at the same time, may not want to pass through the wrong puberty in the gender assigned at birth. Thus, their options for offspring are very limited, since prepubertal cryopreservation is still in the experimental stages [ 33 ]. There are other questions as well, including their maturity for making these kinds of decisions and the responsibility of their parents as legal guardians. In the literature, a few authors reported the desire of transgender people to have children and found that about half of both trans-men and trans-women wanted offspring after transition [ 29 , 34 ].

Cryopreservation of embryos, oocytes, or ovarian tissue is a viable option for trans-men. Some authors recommend cryopreservation just before initiation of hormonal transition due to the possibility that cross-sex hormone therapy might cause amenorrhea or affect follicle growth. In cases where the hormonal transition has already started, they suggest an interruption of hormone treatment for minimum 3 months with a goal to revert any potential therapy-induced effects [ 35 ]. These could be very aggravating facts, since other doctors reported that majority of transgender individuals did not want to postpone their transition for these procedures. Interestingly, Wallace et al. noticed that transvaginal ultrasound examination, as a necessary part for cryopreservation of embryos and oocytes, is not always in accordance with individuals' male identity and can lead to distress [ 36 ].

Sperm cryopreservation, surgical sperm extraction, and testicular tissue cryopreservation could be offered as possibilities for preserving fertility in trans-women. The issues with hormonal therapy exist in this case, too. De Sutter et al. described additional distress, caused by masturbating in clinical settings or sperm banking as a reminder of their former gender [ 34 ].

In some countries, cryopreservation is not technically available to the transgender population and thus cannot be offered during the transition. Despite the fact that cryopreservation is a routine procedure in case of malignant diseases, it still remains a controversial topic in less economically developed countries.

In some countries, like USA, sterilization is not mandatory and trans-men can keep their ovaries and uterus for later pregnancy. They must discontinue cross-sex therapy in this period. Light et al. described transgender pregnancies and challenges that come with this phenomenon [ 37 ]. Conversely, pregnancy is still not an option for trans-women. There is hope on the horizon from the first successful uterus transplantation, performed by a gynecology team from Sweden [ 38 ]. This is a solution for all women suffering from absolute uterine infertility who want to carry their own children. This procedure brings a new insight for researchers, making the possibility for transplantation in trans-women realistic. The main problems could arise from the different anatomy of the male pelvis, as well as from immunosuppressive therapy.

Fertility, including all the related issues and dilemmas, should be discussed very profoundly and meticulously. Transgender population should be informed about all possibilities, advantages, and drawbacks before any treatment and each option should ultimately be the patient's decision.

4. Regret and Revision Surgery

There are various levels of regret after GAS. Definite regret happens when the patient wants to get back to their gender assigned at birth after the GAS is performed. They come to surgeons with the request for the restitution of congenital anatomical features. Regret manifests with a more or less pronounced expression of dissatisfaction and second thoughts about the GAS. After suicide, regret could be considered one of the worst possible complications.

Reasons for regret vary greatly. Inadequate social adaptation, comorbidity with certain psychiatric disorders, poor psychological and psychiatric evaluation, and dissatisfaction with aesthetic or functional outcome of GAS can lead to regret. Researchers have concluded that the presence of the following factors can be associated with a risk of regret: age above 30 years at first surgery, personality disorders, social instability, dissatisfaction with surgical results, and poor support from partner or family [ 39 – 41 ].

In 2016, we published a retrospective analysis of seven patients who underwent reversal surgery after regretting undergoing male-to-female GAS elsewhere [ 42 ]. Main reasons for regret in these cases were related to inadequate psychiatric assessment. First stages of transition like the “real-life experience” were mostly skipped, cross-sex hormonal therapy was not carried out properly, and letters of recommendation were written by psychiatrists who lacked experience. Also, main diagnostic criteria for gender dysphoria had been neglected. It is therefore important to avoid situations where inadequately trained or inexperienced psychologists or psychiatrists work with transgender patients without supervision or collaboration with more experienced colleagues. Satisfying postoperative results were achieved in all patients. Reversal surgery significantly enhanced their general well-being.

Each regret occurrence represents a major issue for every expert in the field of transgender medicine. Proper diagnosis and listening to and monitoring our patients are of crucial importance for avoiding these kinds of mistakes [ 43 ]. Every physician should be aware that not all individuals suffering from GD want or need all three elements of therapy.

5. Conclusion

All physicians included in gender dysphoria treatment are facing great bioethical challenges and dilemmas. A multidisciplinary approach is necessary, but it does not always guarantee a successful outcome. The most sensitive issues are the treatment of transgender youth, fertility and parenting in transgender individuals, and the risk of regret after the irreversible part of the treatment, the gender affirmation surgery. In order to avoid the complex issue of regret, proper preoperative evaluation by experienced professionals, psychologists, and psychiatrists is necessary. More research and studies are necessary to shed light on these issues.

Acknowledgments

This work is supported by Ministry of Science and Technical Development, Republic of Serbia (Project no. 175048).

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

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Delaying Gender Affirmation Until Adulthood is Unethical

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Gender Dysphoria occurs when there is a misalignment between the experienced gender of an individual with their gender assigned at birth and can cause stigmatization, difficulties building relationships, and poor self-esteem.

Silhouettes of heads and faces appearing to be traditional male or female construct, and some undefined or blended together.

Lexi McGowan is double majoring in biology and public health with a minor in chemistry and is a 2022-23 health care ethics intern at the Markkula Center for Applied Ethics . Views are her own.

Gender Dysphoria occurs when there is a misalignment between the experienced gender of an individual with their gender assigned at birth. This incongruence with the binary can cause stigmatization, difficulties building relationships, poor self-esteem, and eventually depression and anxiety . It is important for youth to go through a psychodiagnostic evaluation to determine the presence of gender dysphoria and determine the best steps in moving forward.

This dysphoria typically presents itself during adolescence, and risks self-harm or potentially suicide. Passing through the “wrong puberty” is extremely harmful to youth and the development of their social relationships. The gender reassignment process improves this psychological health. 

Delayed Transitions: Risks of Anxiety and Depression

Supporting children in their identities allows them to thrive. Puberty-suppressing gonadotropin-releasing hormone analogues (GnRH) are a reversible treatment option for early stages of gender dysphoria. Further along, there are also options for partially reversible treatments, such as gonadal steroid treatment, or surgical interventions (modifying/removing/reconstructing genitalia) which are irreversible. 

Puberty suppressants allow youth to halt the development of secondary sexual characteristics. This prevents passing through the wrong puberty, and allows extra time for cognitive development and exploring their gender. One study on transgender youth who were allowed to socially transition found that levels of anxiety and depression among this group were not significantly different from those who were not transgender.

In another study , GnRH analogues were used among youth ages 12-16 years old. Psychological functioning and gender dysphoria were assessed twice: once before the start of GnRHa and once after, just before cross-sex hormones were introduced. They found behavioral and emotional problems, as well as depressive symptoms, decreased between the two measurements. They also found the natal females in the study were older when they began the process, and had higher levels at both time periods, compared to the natal males. This may indicate the value of beginning treatment at earlier ages.

A study on young adults who completed all three stages of transitioning found improvements in gender dysphoria, psychological functioning, and found their well-being to be comparable to young adults in the general population, specifically after reassignment surgery. Allowing youth to complete all stages of gender reassignment gives them the chance of successfully developing into adults with similar experiences and functionings of their peers.

The Risk of Changing Minds or Regret

It is often argued that it is wrong to begin transitioning youth before they reach the legal age of consent, and that gender dysphoria is simply a phase youth are going to pass through. However, when 55 transgender people were given puberty blockers during adolescence, the study found that no one experienced regret or changed their minds. Once puberty is reached, transgender youth are very unlikely to change their gender identity, which is when irreversible medical intervention can begin. Starting with puberty blockers would allow a buffer in the unlikely event one was to change their mind. Although importantly, another study noted that no adolescent stopped puberty suppressants, and all went on to begin hormone treatments.

The Safety of Medical Treatments

Another prominent concern of transitioning youth is whether or not the treatments are safe, and how they can impact physical health. The puberty suppressant implant is shown to have some mild side effects , including decreasing bone density. Luckily, once the implant is removed and hormone treatment is initiated, this quickly resolves itself. 

Puberty suppressants and hormone therapy can impair fertility. A current solution is offering fertility preservation options, including freezing sperm/eggs so they can access them later on to build a family.

At a minimum, allowing hormone treatment while continuing GnRHa can allow the individual to go through puberty in alignment with their gender identity, and combat dysphoria, before taking on the obvious risks of surgical intervention. Forcing one to undergo the wrong puberty is far more harmful than the risks of early treatments.

Unfortunately, there are still limitations within the research surrounding the safety and efficacy of the use of GnRHa in children under the age of 12, and for hormone treatments in those under the age of 16. This is where current research needs to be focused, as many youth begin puberty before the age of 12. 

How Young is Transitioning Ethical?

Not many years ago, the use of puberty blockers and starting hormone treatment would have been considered malpractice by doctors. Many adults share stories of how beneficial it would have been for their children to avoid going through the wrong puberty. But also consequently, the use of puberty blockers without hormones/surgery limits the individual from developing at the same rate as their classmates. This is why it is essential to begin treatments as soon as possible, especially puberty blockers and cross-sex hormones. Gender-affirming surgery should also be allowed to begin earlier, but this should follow the recommendation by medical professionals and a psychologist (as this is completely irreversible and significantly life-altering). 

The four principles of ethics: beneficence, nonmaleficence, autonomy, and justice, are all relevant when considering the controversy of youth gender affirmation. Physicians must consider the risks and avoid causing harm to the patient, and it is also important to do what is best for the mental health, well-being, and development of the child by affirming their gender identity. Clinicians must help the individual in all ways possible with puberty blockers and hormonal treatments, as they are currently the safest developments available. This is the duty of beneficence. Failing to do so can have detrimental psychological consequences. In terms of justice, transgender youth have the right to go though the correct puberty, just as their peers do. Getting affirmed and accepted in their identified gender is a right, and all youth should have, and need, access to this.

Perhaps most prevalent in this discussion is the right to autonomy. The individual must have autonomy over what treatments they pursue and what they do with their own body. But the main issue is at what age should transgender youth be able to do this? 

The current age for surgical procedures in the U.S. is 18 . Hormonal therapy can begin when there is confirmed gender dysphoria and adequate mental capacity for informed consent, including an understanding of the risks, at age 16 . Parental consent is also required for any treatments when the patient is under the age of 18.

I argue that delaying this treatment, even to 16, can become not only detrimental to bone health of the individual, but also harmful to their mental health by keeping them in a prepubertal state that inevitably leads to isolation and harm to well-being. I also argue that requiring parental consent, therefore possibly delaying treatment, can be detrimental to the subset of children who do not have this support. 

Exceptions do not currently exist for children when their parents do not consent. Following the model of the UK , the courts should be able to overrule lack of parental consent if the treatment would be in the best interests of the child. 

While children do not have legal power in decision making, it is important to look at this on a case-by-case basis , to initiate treatments as soon as they are deemed mentally fit to consent, as some youth develop, mentally and physically, quicker than others. This individualized approach will ensure the right decision is made for the specific child, as it will be in accordance with their age and maturity. Discussions of risks and advantages are crucial in this time period, and should begin even earlier to allow time for thoughtful analysis by the individual and their family. 

Common practice needs to be allowing youth to begin transitioning genders when they feel ready, following a psychological consultation and evaluation, in order to improve mental health outcomes. In order to do this, more research is needed, and should be prioritized, for the youngest age that is medically safe to begin puberty blocker and cross-sex hormone therapy.

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The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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When we fall prey to perfectionism, we think we’re honorably aspiring to be our very best, but often we’re really just setting ourselves up for failure, as perfection is impossible and its pursuit inevitably backfires.

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Gender-affirming medical treatment for adolescents: a critical reflection on “effective” treatment outcomes

• Ezra D. Oosthoek 1 , 2   na1 ,
• Skye Stanwich 1 , 2   na1 ,
• Karl Gerritse 1 , 2 ,
• David Matthew Doyle 1 , 3 &
• Annelou L.C. de Vries 1 , 2  

BMC Medical Ethics volume  25 , Article number:  154 ( 2024 ) Cite this article

Metrics details

The scrutiny surrounding gender-affirming medical treatment (GAMT) for youth has increased, particularly concerning the limited evidence on long-term treatment outcomes. The Standards of Care 8 by the World Professional Association for Transgender Health addresses this by outlining research evidence suggesting “effective” outcomes of GAMT for adolescents. However, claims concerning what are considered “effective” outcomes of GAMT for adolescents remain implicit, requiring further reflection.

Using trans negativity as a theoretical lens, we conducted a theory-informed reflexive thematic analysis of the literature cited in the “Research Evidence” section of the SOC8 Adolescents chapter. We selected 16 articles that used quantitative measures to assess GAMT outcomes for youth, examining how “effective” outcomes were framed and interpreted to uncover implicit and explicit normative assumptions within the evidence base.

A total of 44 different measures were used to assess GAMT outcomes for youth, covering physical, psychological, and psychosocial constructs. We identified four main themes regarding the normative assumptions of “effective” treatment outcomes: (1)  doing bad: experiencing distress before GAMT , (2)  moving toward a static gender identity and binary presentation , (3)  doing better: overall improvement after GAMT , and (4) the absence of regret . These themes reveal implicit norms about what GAMT for youth should achieve, with improvement being the benchmark for “effectiveness.”

We critically reflect on these themes through the lens of trans negativity to challenge what constitutes “effective” GAMT outcomes for youth. We explore how improvement justifies GAMT for youth and address the limitations of this notion.

Conclusions

We emphasize the need for an explicit discussion on the objectives of GAMT for adolescents. The linear narrative of improvement in GAMT for adolescents is limited and fails to capture the complexity of GAMT experiences. With currently no consensus on how the “effectiveness” of GAMT for adolescents is assessed, this article calls for participatory action research that centers the voices of young TGD individuals.

Peer Review reports

Introduction

This article appears during a critical moment in the provision of gender-affirming medical treatment Footnote 1  (GAMT) for youth. Discussions around the safety and efficacy of GAMT for youth are becoming increasingly widespread, along with growing criticism regarding the lack of longer-term evidence for GAMT outcomes. Given this context, we believe it is relevant to reflect on what evidence substantiates “effective” outcomes of GAMT for adolescents, and to examine which treatment outcomes justify and legitimize GAMT for adolescents. Thereby, we seek to open up conversations about what good research evidence for GAMT for youth consists of. To do so, this article reviews the cited literature in the “Research evidence of gender-affirming medical treatment for transgender adolescents” section of the Standards of Care 8 (SOC8), developed by the World Professional Association for Transgender Health (WPATH) (1 pp45-47). This section addresses the evidence base of GAMT for adolescents by outlining research evidence that presents “effective” outcomes. However, claims concerning what should be considered “effective” outcomes of GAMT for adolescents remain implicit within the document, leaving room for further reflection.

Drawing from the interdisciplinary field of trans studies , we introduce trans negativity as a theoretical lens to critically reflect on the implicit and explicit normative assumptions underlying “effective” GAMT outcomes. Trans negativity examines how negative affect – such as distress and suffering – plays a crucial role in both medical and socio-cultural narratives surrounding gender transition. It highlights how negative affect is deeply embedded in the pathologization and medicalization of TGD identities and the curative discourse surrounding GAMT, and critiques the framing of negative affect as a problem to be resolved through medical intervention. Using this perspective, we critically analyze the normative assumptions underpinning the SOC8 research evidence and argue for acknowledging the intrinsic complexity of GAMT, including the often enduring presence of negative affect throughout and beyond transition [ 1 , 2 , 3 ]. In doing so, this paper ultimately seeks to reflect on GAMT treatment outcomes used as benchmarks for “effectiveness” and to foster discussion on the ethical question of what constitutes good outcomes of GAMT for adolescents.

While the existence of trans and gender-diverse Footnote 2 (TGD) youth seeking gender-affirming medical care is not a new phenomenon [ 4 ], GAMT for youth has developed rapidly in the past two decades, particularly concerning puberty suppression and hormone replacement therapy [ 5 , 6 ]. As the visibility of (young) TGD individuals has increased, so too has the scrutiny surrounding GAMT for this demographic, prompting increasingly polarizing debates within both the healthcare community and society at large [ 7 , 8 , 9 , 10 , 11 ]. The controversies surrounding GAMT for youth are reflected in the growing number of restrictions on the provision of this care in various countries [ 12 ]. In the United States, an increasing number of anti-trans bills are restricting – and even criminalizing – this care practice [ 13 , 14 ]. These limitations to accessing GAMT are increasingly paralleled in Europe. For example, in Sweden, pediatric endocrinologists now only prescribe puberty suppression under strict conditions [ 15 ]. Similarly, NHS England recently made the decision to reorganize the provision of GAMT for TGD youth and restrict the prescription of puberty suppression, further highlighting the precarity of this medical treatment [ 16 , 17 , 18 ].

A central aspect of the scrutiny leveraged at this care practice is the critique that there is insufficient evidence regarding the treatment outcomes of GAMT for youth, which contributes to rising uncertainties about the long-term effects of treatment [ 19 , 20 ]. In turn, some concerned critics have deemed the current research to be insufficient and have called for a strengthening of the evidence base for GAMT for youth [ 18 , 21 , 22 ]. Not only are questions arising regarding the quantity of research in this field, but critics are also concerned with the quality of the available evidence [ 21 ]. Recent systematic reviews have graded the quality of the current evidence base for this care as relatively low, due primarily to the absence of randomized controlled trials [ 23 , 24 ]. Understandably, clinicians and clients alike seek to base treatment decisions on the best available evidence; a high quantity and quality of evidence enables healthcare providers to feel reassured in medical decision-making and helps to provide a sense of order in navigating the uncertainty that is inherent to medical care in general, and GAMT for youth in particular [ 25 , 26 ]. This heightened uncertainty around GAMT for adolescents relates to concerns about their capacity to make long-term decisions about their future [ 22 , 27 , 28 ], especially when it comes to decisions about fertility and the potential risk of regret later in life [ 19 , 29 , 30 ]. These concerns are intertwined with the understanding of adolescence as a critical developmental period during which identity is still in development. Some argue that no GAMT interventions – especially irreversible ones – should be performed during this stage [ 19 , 21 ].

Furthermore, typical evidence-based medicine practices (i.e., relying on scientific evidence and clinical expertise) may not always help to inform decision-making in this context [ 25 ]. Meeting the “gold-standard” of evidence-based medicine can help to legitimize the provision of care, protecting against criticism that treatment approaches are unfounded [ 31 , 32 , 33 ]. However, some scholars argue that meeting this “gold-standard” through performing randomized controlled trials in transgender adolescent care is both methodologically inappropriate and unethical as it may deny or delay treatment, thereby making it difficult to recruit participants willing to risk being assigned to a non-treatment group [ 27 , 34 ]. Given this context, the “gold-standard” of evidence-based medicine has not been considered suitable for guiding research practices for GAMT for youth, which is believed to contribute to uncertainty around the legitimacy of this care practice and its evidence base [ 25 ]. Despite the criticism surrounding GAMT for youth and its corresponding evidence base, experts within the field of transgender adolescent care have aimed to systemize care by integrating available evidence, patient values, and clinical expertise to create care models [ 26 , 35 ].

WPATH and the SOC8

Currently, the most widely adopted care model for GAMT is likely the SOC by the WPATH, an international, multidisciplinary, professional association whose mission is to promote evidence-based transgender healthcare [ 35 ]. The first version of the SOC, published over four decades ago when GAMT was not yet regulated as it currently is, sought to establish quality guidelines for this care practice. Furthermore, the SOC outlined eligibility criteria to determine who may qualify for GAMT interventions, Footnote 3 such as hormone replacement therapy and/or surgical care [ 35 , 36 ]. Since its inception, experts within WPATH have continuously collaborated on and updated the SOC, which are now widely implemented in local care guidelines in multidisciplinary clinics around the world. The latest version, the SOC8 (released in 2022), Footnote 4 provides guidance on various aspects of trans-specific healthcare, including mental health, puberty suppression therapy, hormone replacement therapy, and surgical care.

In response to the growing demand for a more robust evidence base, the authors of the SOC8 state that the current document is “based upon a more rigorous and methodological evidence-based approach than previous versions,” building on published literature as well as consensus-based expert opinion (1 p8). The present state of the field consists of a limited number of GAMT outcome studies that follow TGD youth throughout their treatment trajectories into adulthood. As a result, the authors of the SOC8 Adolescents chapter point out that they could not conduct a systematic literature review of treatment outcomes in adolescents akin to that executed in, for instance, the chapter on Hormone Therapy [ 35 ]. Instead, a short narrative review on GAMT outcomes in adolescents was provided in the SOC8 Adolescents chapter, suggesting that the evidence base for GAMT for youth is in fact growing, and the best available evidence “indicates [that] providing gender-affirming treatment for gender diverse youth who meet criteria leads to positive outcomes” and “can be effective and helpful for many transgender adolescents” (1 p47,65, emphases added). However, the assertion of “effective” and “positive” outcomes of GAMT for adolescents raises questions about the underlying value judgments defining what constitutes desirable outcomes, which often remain implicit in the literature.

Given this background, this article aims to address the following questions: what are considered “effective” treatment outcomes in the SOC8 Adolescents chapter and how are normative assumptions regarding GAMT reflected through these outcomes? Informed by trans negativity as a theoretical lens, we perform a theory-driven reflexive thematic analysis of the cited literature in the “Research Evidence” section in the SOC8 Adolescents chapter. We analyze the cited literature in this particular section of the SOC8 Adolescents chapter with the aim to (1) provide an overview of the treatment outcomes in the cited literature of the research evidence in the SOC8 Adolescents chapter used to substantiate “effective” outcomes of GAMT for adolescents and (2) to elucidate normative assumptions underlying these treatment outcomes. By examining these assumptions through the lens of trans negativity, we seek to gain a more explicit understanding of how “effective” GAMT outcomes are defined throughout the evidence-base and interpreted by the SOC8 authors, as well as the underlying values that shape these definitions. To be clear, this article does not seek to question the importance or necessity of GAMT, but rather to critically reflect on claims regarding its “effectiveness” for TGD adolescents and how these claims are used to justify this care practice. Through our analysis, we aim to open up the conversation on what constitutes “effective” GAMT outcomes, particularly in relation to the diverse and often complex transition experiences of TGD youth.

Theoretical lens: trans negativity

The prevailing narrative of being “born in the wrong body” has long dominated the medical discourse on TGD individuals, often portraying GAMT as a “cure” aimed at aligning individuals with dominant heteronormative gender norms [ 37 , 38 , 39 ]. TGD individuals have often been depicted as deviating from the norm, in turn framing medical gender transition as a means to attain a congruent, (hetero)normative gender identity and gender expression [ 37 , 39 , 40 , 41 ]. Historically, the pathologization and medicalization of TGD experiences have been pervasive in both the medical community and society at large [ 42 ]. While the field of GAMT is making efforts to move away from the pathologization of TGD individuals and towards destigmatization and affirmation of TGD identities, the medical diagnoses of gender dysphoria [ 43 ] and gender incongruence [ 44 ] persist in order to validate and insure the provision of GAMT [ 35 , 45 , 46 ].

Critiquing the pathologization and medicalization of TGD individuals, trans studies was established as an interdisciplinary field to address the historical erasure and exclusion of trans and gender non-conforming people within academic discourse [ 47 ]. Trans studies is concerned with the study of gender and the experiences of TGD individuals, examining social, cultural, historical, political, and medical facets of gender while also exploring other intersections such as race, ethnicity, class, and disability. Central to trans studies are critiques of the normative biomedical framing of gender transition challenging restrictive binary narratives that depict gender transition as a linear journey from man to woman or vice versa [ 48 , 49 ].

An important aspect of this critique, informed by feminist and queer affect theory, is the role of negative affect – or feeling bad – in the context of GAMT. Feminist and queer affect theory (e.g., [ 50 , 51 , 52 , 53 ]) offers tools to explore how affective experiences are shaped by cultural, social, and political forces. This framework provides a useful lens for understanding the persistence of negative feelings throughout and beyond gender transition, challenging the dominant view of GAMT as a linear, teleological process aimed at achieving alignment between one’s gender identity and body, ultimately leading to a coherent sense of self. This prevailing narrative is shaped by the expectation that transition should lead to improvement , implying that each step in the transition process mitigates negative feelings, ultimately “curing” gender dysphoria and improving the well-being of the TGD individual [ 2 , 39 ]. Importantly, this perspective extends beyond the medical community; it is also prominent among TGD activists and advocates for transgender healthcare who emphasize the life-saving potential of gender-affirming interventions, particularly in preventing suicide and improving life satisfaction [ 54 ].

While theorizations on the persistence of negative affect throughout and beyond GAMT encourage critical reflection on the premise of GAMT as leading to physical alignment as well as psychological and psychosocial improvement , these insights have primarily remained within the realm of trans cultural theory, with limited integration into biomedical research or transgender healthcare [ 1 , 2 , 3 ]. As authors, we see value in bridging these disciplines to foster more nuanced and interdisciplinary conversations within transgender healthcare.

We conducted a theory-informed reflexive thematic analysis of textual materials to examine the literature cited in the “Research Evidence” section in the SOC8 Adolescents chapter [ 55 , 56 ]. Our dataset consisted of 16 articles Footnote 5 from this section of the SOC8, which we selected based on their use of quantitative outcome measures to assess GAMT for youth. The articles were selected from a total of 24 cited sources in the “Research Evidence” section. For the purposes of our analysis, we chose to focus only on literature that presented treatment outcomes of GAMT. Sources that were excluded used qualitative methods [ 57 , 58 ], extracted data from medical files or care records [ 59 , 60 , 61 ], were case presentations or reports [ 27 , 62 ], or focused on detransition needs [ 63 ]. We recorded each of the outcome measures utilized in these sources and subsequently grouped these into six categories (see Results). These categorizations were developed based on how the authors in the cited sources used, described and employed each measure, reflecting the intended outcomes the measures aimed to assess. Importantly, many of these measures are broadly defined, overlapping, or are used by various authors in different ways.

We focused our thematic analysis on the introduction, discussion, and conclusion sections of these articles to gain comprehensive insights into the study aims and authors’ interpretations regarding “effective” GAMT outcomes. A specific focus on these sections allowed us to understand how the authors framed their studies and interpreted GAMT outcomes, highlighting what were considered “effective” outcomes of GAMT for adolescents. Although we did not code the remaining sections for the thematic analysis, we reviewed the methods and results sections of these articles to document the wide variety of measures used in each study (see Table  1 ). In line with the principles of reflexive thematic analysis, our approach was intentionally subjective [ 55 , 56 ]; our codes and themes represent our interpretations, and these are informed by our subjectivities and the theoretical lens through which we approach this research. Throughout the analysis process, the author team frequently reflected upon and discussed our interpretations of the data with one another.

Following Braun and Clarke’s [ 56 ] process for reflexive thematic analysis, our first step was to familiarize ourselves with the data, in which the first two authors (EO and SS) initially read all of the articles. Upon re-reading, both authors took note of passages that stood out and identified patterns shared between the articles (e.g., the aims of the studies and the conclusions that were drawn based on GAMT outcomes). Subsequently, we uploaded the articles into MAXQDA (version 2022) to begin coding. We primarily utilized a deductive coding approach [ 56 , 76 ]. Informed by trans negativity as a theoretical lens to interpret and extract meaning from the data, we were particularly attentive to cues in the articles indicating a sentiment of “improvement” vis-a-vis GAMT outcomes. However, we did not have an a priori codebook, thus we also used inductive coding by employing open codes that pertained to potentially relevant themes in the text. The first two authors independently coded the designated sections of the articles and labeled relevant content. After the initial coding, they compared their code list and, upon consensus, identified initial themes and subthemes. Multiple rounds of coding were performed to capture all significant themes. We further developed and reviewed these themes with all authors, and once inconsistencies were resolved through discussion, we generated a coding tree along with a final set of themes. Lastly, EO and SS reviewed the relevant quotes for each theme and created a table of exemplar quotes (see Table  2 ) which was later reviewed and agreed upon by all authors.

Positionality statement

A central aspect of reflexive thematic analysis is acknowledging that researchers’ positions influence the research process, inviting researchers to critically reflect on their subjectivity and positionality [ 55 ]. We, the authors, comprise a mix of junior (EO and SS) and senior researchers (KG, DD, and AV). The first two authors (EO and SS) are PhD candidates with a background in Gender Studies and Sociology. KG is a trained ethicist and psychiatry resident with clinical and research experience in GAMT. DD is an academic researcher trained in social and medical psychology whose work primarily focuses on members of marginalized groups. AV is a child psychiatrist and senior researcher with extensive clinical and research experience on adolescent transgender care and served as a co-author on the SOC8 Adolescents chapter. All authors are currently affiliated with the Center of Expertise on Gender Dysphoria (CEGD) in Amsterdam, the Netherlands. The authors represent varying gender identities and sexual orientations, including trans, queer, and cis. Footnote 6 One of the authors has experience with accessing GAMT in the Netherlands as a young adult. All of the authors are White, highly educated, live in a high-income country, have academic affiliations, and hold Western citizenship. While our professional and personal backgrounds offer different perspectives on GAMT for adolescents, we acknowledge the limitations in our insight into specific challenges at various intersections of TGD identities in terms of race, class, and (dis)ability.

As authors, we understand the precariousness of this care practice, experiencing it as both recipients and providers of GAMT. Like the authors of the SOC8, we acknowledge the progress made in the provision of GAMT and its significant potential in enhancing the overall physical and psychological health of TGD individuals. We recognize the risks associated with subjecting GAMT outcomes to critical scrutiny, especially given the ongoing limitations on its provision in several countries. Many proponents of GAMT for adolescents have responded to these care restrictions by emphasizing “positive” research outcomes (i.e., improved well-being, low regret rates etc.) which is both valuable and necessary. While this article takes a different approach, aiming to build upon existing work, our intention is not to question the value of GAMT for TGD youth. Instead, we aim to question claims that GAMT must necessarily result in “effective” outcomes in order to be considered legitimate and essential care. Our intention, then, is not to undermine the legitimacy of GAMT but rather, echoing Malatino [ 2 ] and Saketopoulou and Pellegrini [ 77 ], to articulate the complex and ambivalent experiences of gender transition. Our interest, as such, lies in making space for diverse perspectives on what GAMT ought to do, moving beyond normative notions of improvement that might limit the diverse experiences and needs of TGD individuals.

Overview of measures

Throughout these 16 cited sources, we identified 44 different measures in total that were used to quantitatively assess and evaluate the “effects” of GAMT for adolescents (see Table  1 ). These measures assessed constructs which we have classified under the following categories: gender dysphoria and body dissatisfaction, psychological functioning, global functioning, social functioning, quality of life, and satisfaction with care. Many of these measures pertained to psychological functioning (20 of the 44 measures), and only four of these measures assessed gender dysphoria and body dissatisfaction. In terms of how frequently authors measured each of these constructs, psychological functioning was most often measured, assessed in 14 of the 16 studies. Gender dysphoria and body dissatisfaction was the second most frequently assessed construct ( N  = 9), followed by social functioning ( N  = 6), quality of life ( N  = 6), global functioning ( N  = 4), and satisfaction with care ( N  = 3).

Reflexive thematic analysis

Using trans negativity as a theoretical lens [ 1 , 2 , 3 ], we analyzed the cited literature in the “Research Evidence” section of the SOC8 Adolescents chapter and identified four interrelated themes that are used to substantiate “effective” treatment outcomes for GAMT for adolescents. These themes pertain to (1)  doing bad: experiencing distress before GAMT , (2)  moving toward a static gender identity and binary presentation , (3)  doing better: overall improvement after GAMT , and (4) the absence of regret . Although these four themes do not all directly describe treatment outcomes of GAMT, together they represent a prevalent narrative throughout the literature that exemplifies what GAMT is expected to treat, as well as how an “effective” GAMT trajectory is commonly described.

We present the themes in this particular order to emphasize the teleological narrative commonly portrayed in medical literature, which we aim to challenge: a progression from “doing bad” to “doing better,” ultimately leading to an overall improvement in the individual’s functioning and well-being. This narrative also suggests that gender identity is potentially malleable during adolescence but tends toward a stable endpoint, solidifying into a static identity in young adulthood. Furthermore, it suggests movement within a binary understanding of gender, portraying gender transition as a chronological process with a clear beginning and endpoint. Such a framing of gender transition upholds the dominant understanding of GAMT as a linear process with a stable, teleological outcome. Central to these themes is a pervasive “logic of improvement,” implying that GAMT is “curative,” supposedly guiding TGD individuals from “doing bad” to “doing better” in a linear, teleological manner. In the subsequent sections, we will discuss how each theme reveals the underlying expectations that define the perception of GAMT as “effective,” reflecting broader discourses on the objectives and outcomes of GAMT for adolescents.

Theme 1. Doing bad: experiencing distress before GAMT

The first theme encapsulates the profound physical, psychological, and psychosocial distress experienced by TGD adolescents. Throughout the cited literature in the SOC8 “Research Evidence” section, distress is frequently identified as the primary “target” of GAMT, suggesting that one of its key objectives is to alleviate or even resolve this distress. Furthermore, this distress is often attributed to gender dysphoria experienced by TGD youth. Although the Body Image Scale (BIS) and the Utrecht Gender Dysphoria Scale (UGDS) were commonly used to measure and evaluate body (dis)satisfaction and (the intensity of) gender dysphoria respectively, a substantial proportion of the cited articles (7 out of 16) did not use either of these measures [ 19 , 70 , 71 , 72 , 73 , 74 , 75 ]. Instead, they focus on assessing constructs such as global psychosocial functioning and psychological well-being (see Table  1 ).

In this cited literature, gender dysphoria is commonly characterized as an incongruence between the individuals’ body and their identity: “a conflict between a person’s physical or birth-assigned sex and the gender with which that person identifies and the wish to receive medical interventions that modify the body” (21 p1). Authors describe that gender dysphoria is “often accompanied by psychological distress and a persistent strong desire for social and physical gender changes” (71 p633). Notably, in many countries, a diagnosis of Gender Dysphoria accompanied by distress is a requirement for accessing GAMT [ 35 ]. If gender dysphoria refers to a persons’ distress, then a certain level of distress (i.e., “doing bad”) must be experienced to receive GAMT. Footnote 7 This distress, however, remains ambiguous in how it is defined and identified.

Although few authors acknowledge the diversity in TGD peoples’ experiences, Allen et al. (69 p302) note that “transgender people have varying degrees of GD; some have none at all,” acknowledging that “distress” can manifest differently for different people. The distress experienced by TGD adolescents often extends beyond the physical discomfort associated with gender dysphoria to include psychological and psychosocial challenges that affect social interactions, school, and other critical aspects of life [ 20 ]. All 16 studies highlight the psychological effects of this distress, and the risk of this distress worsening if GAMT is withheld. As Costa et al. (75 p2207) state:

Despite many years of psychotherapy the [gender dysphoria] of most adolescents does not often abate. Rather, once these young persons, who are already experiencing considerable distress over their gender identity, undergo the pubertal development of their biological sex, their psychological well-being deteriorates significantly.

As the literature describes, TGD youth are disproportionality burdened by poor mental health outcomes before receiving GAMT, including depression, internalizing disorders, behavioral problems, anxiety, and suicidal ideation and attempts [ 66 , 70 , 72 ]. Achille et al. (70 p3) report that this distress becomes pronounced during adolescence, a period characterized as “a particularly difficult time for transgender persons who experience the development of secondary sexual characteristics that are incongruous with their gender identity, and is associated with a high prevalence of depression and suicidal thoughts and gestures.”

The intense distress experienced by TGD adolescents is highlighted by Cohen-Kettenis and Van Goozen (77 p264), who note that TGD individuals showing “an extreme pattern of cross-gender identification from their earliest years, suffer deeply.” Consequently, delaying initiation of GAMT “engenders feelings of hopelessness and slows down their social, psychological, and intellectual development,” suggesting that “early treatment would prevent much unnecessary suffering” throughout (young) adulthood (77 p264). By emphasizing the negative experiences of TGD youth including physical, psychological, and psychosocial distress, specifically before receiving GAMT, these authors justify the benefits of and necessity for gender-affirming medical interventions, emphasizing the urgency for appropriate and effective support for TGD adolescents.

However, an underlying uncertainty around the “effectiveness” of early intervention remains present throughout the cited literature. For instance, De Vries et al. (8 p697) acknowledge that “despite the apparent usefulness of puberty suppression, there is only limited evidence available about the effectiveness of this approach.” Almost all articles (15 out of 16) highlight the limited evidence-base supporting the provision of GAMT for TGD adolescents [ 6 , 19 , 20 , 29 , 62 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ]. Becker-Hebly et al. [ 19 ] note that the numbers of studies providing evidence that both puberty suppression and GAH therapy can improve multiple, but not always all, aspects of psychosocial health remains small. Furthermore, critics of GAMT for adolescents express concerns that suppressing puberty may even negatively affect psychological functioning [ 65 ]. As such, the ambiguity surrounding the “effectiveness” of (early) GAMT for TGD adolescents stresses the complexity of this care practice. This uncertainty appears to arise from both the limited evidence base and the ambiguous ‘nature’ of the distress required to receive GAMT, reflecting broader socio-political debates about the object and objectives of GAMT for youth – that is, what GAMT aims to “treat” and “achieve” in the first place [ 48 , 78 , 79 ].

Theme 2. Moving toward a static gender identity and binary presentation

The second theme we identified concerns the linear and predetermined nature of gender identity development and gender transition. Throughout the cited literature in the SOC8 section, both gender identity development and gender transition tend to be depicted as teleological, unidirectional processes.

Drawing from the cited literature, it appears that the concept of a linear gender transition toward a fixed endpoint is rooted in the idea that adolescence is a crucial period for the development of gender identity: “identity development during adolescence is in progress and consolidates only later in early adulthood” (21 p1756). Through this framing, gender identity development is perceived as being potentially fluid early in life but is eventually expected to stabilize in a binary way in (young) adulthood. As the authors highlight, a stable, persisting and (often) binary gender identity Footnote 8  thus becomes a prerequisite for receiving GAMT: “clinicians might want to take special notice of MFs [male to females] who report inconsistencies in past and present gender dysphoria” (78 p98). In this context, an unstable gender identity is framed as problematic by Smith et al. (78 p98):

The contradicting presence of more gender dysphoria in childhood but less at application [of GAMT] should alert the clinician when assessing eligibility. This inconsistency may reflect confusion about development, an (unconscious) exaggeration of history if current feelings are not clear-cut, or a conscious effort to mislead the clinician.

However, De Vries et al. (8 p703) note that the persistence of a certain gender identity is not necessarily guaranteed:

Despite the fact that developing evidence suggests that cognitive and affective cross-gender identification, social role transition, and age at assessment are related to persistence of childhood [gender dysphoria] into adolescence, predicting individual persistence at a young age will always remain difficult.

In this context, De Vries et al. [ 6 ] suggest that gender identity might be malleable in childhood, meaning that a more fluid gender identity in childhood might desist and become more fixed into adolescence. However, De Vries et al. (80 p2281) maintain that TGD youth should exhibit a consistent and persistent experience of gender dysphoria – manifested as distress – in order to receive GAMT; “young adolescents who [have] been carefully diagnosed show persisting gender dysphoria into late adolescence or young adulthood” and can benefit from GAMT. The cited literature, which adheres to the SOC8 eligibility criteria for the provision of GAMT for adolescents, imply an underlying assumption that TGD adolescents who would benefit from GAMT can be identified through careful clinical evaluation. Those who are determined to be experiencing persistent and identifiable dysphoria are more likely to access GAMT to “effectively” align the body with the identified gender and to relieve the young individual from suffering.

Suppressing puberty through gonadotropin releasing-hormone analogues (GnRHa) is an important aspect of medical intervention for TGD youth, but its implications are framed differently by various authors. This highlights an important question – and a point of tension – surrounding GAMT for youth: whether puberty suppression allows time for TGD youth to pause and make decisions, or whether it is a first step that will inevitably lead to further treatment. For instance, Carmichael et al. (22 p20) describe the provision of GnRHa as a “pause,” pointing out that “GnRHa does not change the body in the desired direction, but only temporarily prevents further masculinization or feminization.” In this view, suppressing puberty through GnRHa is seen as a temporary measure providing TGD adolescents with additional time to explore their gender identity without the distress caused by the development of secondary sex characteristics, thereby providing time to assess the stability of their gender identity before proceeding with more irreversible medical interventions. Conversely, Costa et al. (75 p2212) argue that puberty suppression allows TGD adolescents “to experience a smooth transition into their desired gender role.” In this context, the authors frame puberty suppression as a first medical step toward achieving a binary gender expression rather than merely a pause for contemplation before continuing with GAMT interventions.

Furthermore, this “smoothness” underlies a key normative assumption in the provision of GAMT for youth; as De Vries et al. (80 p2277) articulate, “if an adolescent continues to pursue GR [gender reassignment], arresting the development of secondary sex characteristics results in a lifelong advantage of a convincing physical appearance.” Cohen-Kettenis and Van Goozen (77 p269) also note that gender-affirming surgeries enabled TGD individuals “to live in the new gender role in quite an inconspicuous way.” These examples highlight the concept of passing – “successfully” being perceived as the desired (binary) gender – and further construct gender transition in a binary manner. As such, these authors frame “effective” GAMT as not only alleviating the aforementioned “distress,” but also as resulting in a congruent, “inconspicuous” binary gender presentation. Allen et al. (69 p303) note that the ability to “pass” might depend on sex differences: Footnote 9 “compared with transgender girls/women, it may be easier for transgender boys/men to integrate socially because of clear vocal changes (i.e., voice deepening) and facial hair growth, which are traditionally seen as indicators of one’s gender.”

These examples illustrate the discourse surrounding GAMT as a teleological process, progressing through distinct stages toward a stable, congruent, and binary gender identity and gender presentation. This portrayal emphasizes a normative understanding of gender development and transition, with a clear beginning of gender dysphoria early in life, persisting throughout adolescence and stabilizing in young adulthood. Such as framing restricts the recognition that fluidity in gender identity is neither abnormal nor pathological [ 30 , 80 , 81 ]. Throughout the literature, the concept of “smoothness” underscores the narrative of a “successful” transition, where individuals seamlessly align with the identified and presented (binary) gender. This notion of a linear and binary transition pathway is closely tied to the expectation of achieving to “pass,” indicating a “successful” transition [ 82 ].

Theme 3. Doing better: overall improvement after GAMT

The third theme describes the multi-faceted improvements observed across various measures of TGD youths’ functioning and well-being following GAMT. These improvements include treatment outcomes spanning a wide range of constructs, from decreased gender dysphoria and body dissatisfaction, to improved global functioning, psychosocial health, mental health, and overall well-being and quality of life.

In nine studies, the alleviation and/or resolution of gender dysphoria, measured through either the BIS, the UGDS, or both, was characterized as a critical result of GAMT [ 6 , 20 , 29 , 64 , 65 , 66 , 67 , 68 , 69 ]. In some studies, gender dysphoria was described as being “cured” after GAMT; Smith et al. (31 p479) report that “gender dysphoria had disappeared after treatment” and, referring to previous studies, De Vries et al. (80 p2281) note that GAMT indeed may “end the actual gender dysphoria.” Although gender dysphoria was considered a primary treatment outcome in these texts, questions remain as to whether it should be the main – or only – treatment target. De Vries et al. (8 p297) reason that, “after all, treatment cannot be considered a success if [gender dysphoria] resolves without young adults reporting they are healthy, content with their lives, and in a position to make a good start with their adult professional and personal lives.” Indeed, in each of the studies, gender dysphoria was not the only reported treatment outcome to evaluate GAMT.

Treatment outcomes of GAMT related to psychosocial functioning reportedly led to enhancements in many aspects of TGD youths’ functioning, “such as mood improvement and school integration” (75 p2212). De Vries et al. (8 p702) report that TGD individuals’ psychological functioning improved, and quality of life, satisfaction with life, and subjective happiness became comparable to cisgender peers of the same age after GAMT. As such, De Vries et al. (8 p702) state that GAMT provides “formerly gender dysphoric youth the opportunity to develop into well-functioning young adults.”

The sentiment that GAMT can lead to a wide variety of improvements, i.e. “doing better” in various domains is a key argument in this literature as to how GAMT can be “effective” or beneficial for TGD youth: “a treatment protocol including puberty suppression leads to improved psychological functioning of transgender adolescents. While enabling them to make important age-appropriate developmental transitions, it contributes to a satisfactory objective and subjective well-being in young adulthood” (8 p703). Furthermore, Cohen-Kettenis and Van Goozen (77 p270) note that, provided they manage GAMT without problems, TGD adolescents have a lot to gain throughout their life course after treatment: “they can catch up with their peers and devote their attention to friendships, partnerships, and career.” Allen et al. (69 p308) echo these broad improvements in well-being: “transgender people tend to have more positive life experiences when they receive gender-affirming care.”

Although many authors highlight the various improvements in TGD adolescents’ lives following GAMT, providing evidence that they are “doing better,” various studies also report minimal or no improvements after GAMT. This highlights a tension in the narrative that GAMT inevitably leads to more positive life experiences and general improvements. For instance, while psychosocial health outcomes of TGD individuals were generally closer to the population norm following GAMT, Becker-Hebly et al. (21 p1763) note that “not all psychosocial health problems seemed to be resolved;” baseline difficulties persisted throughout the follow-up period for TGD adolescents receiving puberty suppression.

Similarly, Carmichael et al. [ 20 ] observe that GnRHa treatment did not bring either measurable benefits or harm to psychological function in TGD adolescents, concluding a lack of significant changes in psychological function, quality of life, or the degree of gender dysphoria. Additionally, Kuper et al. [ 67 ] acknowledge that environmental stresses may not improve after GAMT, and could potentially worsen, especially if they increase the youth’s visibility as a TGD individual. As Smith et al. (78 p97) assert, “alleviation of the gender problem is not equivalent with an easy life.” Indeed, as Turban et al. (72 p11) emphasize, TGD individuals continue to “face a range of other psychosocial stressors that contribute to chronic minority stress, including but not limited to employment discrimination, lack of safe access to public facilities, and physical violence.” These systemic, socio-political factors can greatly impact TGD individuals’ quality of life, well-being, and in turn, the persistence of negative affect [ 75 ]. The idea that GAMT cannot remedy all psychosocial stressors is echoed by Tordoff et al. (74 p2): “initiation of GAHs may present new stressors that may be associated with exacerbation of mental health symptoms early in care, such as experiences of discrimination associated with more frequent points of engagement in a largely cisnormative healthcare system.”

These examples point to the idea that GAMT might not always result in “doing better.” To us, this raises the question of whether GAMT can be considered an “effective” treatment even if it does not consistently lead to improvement. Authors of the reviewed papers note that these outcomes alone might not be representative of the broader context contributing to TGD individuals’ state of well-being. De Vries et al. (8 p702) report “positive” treatment outcomes but acknowledge that this was likely not due to GAMT alone: “the positive results may also be attributable to supportive parents, open-minded peers, and the social and financial support (treatment is covered by health insurance) that gender dysphoric individuals can receive.” They emphasize that healthcare providers in the field “should realize that it is not only early medical intervention that determines this success, but also a comprehensive multidisciplinary approach that attends to the adolescents’ [gender dysphoria] as well as their further well-being and a supportive environment” (8 p703).

Theme 4. Absence of regret

The fourth theme – related to the topic of regret – permeates much of the discussion on treatment outcomes in the cited literature, influencing considerations of eligibility for GAMT, decision-making processes during GAMT, and the criteria for what is considered an “effective” outcome of GAMT.

Several studies discuss regret and the importance of considering and preventing the risk of regret [ 6 , 19 , 29 , 64 , 68 , 74 ]. As Becker-Hebly et al. (21 p1765) assert, this concern is especially pertinent regarding “irreversible” interventions that could result in “possible regret over the body or surgical results.” According to Cohen-Kettenis and Van Goozen (77 p263), regret is particularly important to consider in the context of GAMT for youth: “the chance of making the wrong diagnosis and the consequent risk of postoperative regret is [...] felt to be higher in adolescents than in adults, as a consequence of the developmental phase itself.” This underscores the idea that gender identity in childhood and adolescence is more malleable than in adulthood, potentially increasing the risk of making “wrong” treatment decisions during this development period.

When evaluating regret as an outcome of GAMT, five studies highlight that participants reported minimal or no feelings of regret regarding GAMT. This lack of regret is generally portrayed as a positive and important result, reinforcing the idea that feelings of regret are an “unfavorable result” and “a matter of serious concern” (31 p472). Similar to Cohen-Kettenis and Van Goozen [ 64 ], Smith et al. (78 p90) emphasize the importance of avoiding postoperative regret: “considering the invasive and irreversible treatment of SR [sex reassignment], it is imperative to try and prevent postoperative regret. This requires the identification of predictors of regret.” Nevertheless, they report that “the vast majority expressed no regrets about their SR [sex reassignment]” (78 p96). Mentioning that poor surgical outcomes can lead to psychopathology and dissatisfaction, De Vries et al. (8 pp700-701) highlight that all young adults in their study were generally satisfied and that “none of the participants reported regret during puberty suppression, CSH [cross-sex hormone] treatment, or after GRS [gender reassignment surgery].” Nieder et al. (71 p633) seem to interpret the process of assessing TGD youths’ eligibility for GAMT as being intended as a means to prevent the potential of regret in the future: “adolescents and young adults rarely regret or stop TRMIs [transition-related medical interventions], provided they fulfill the criteria for a [gender dysphoria] diagnosis and their readiness for treatment is sufficiently assessed.” An important finding then, Nieder et al. (71 p641) state, “is that no adolescents and young adults in the present study regretted TRC [transition-related care] at the time of follow-up, mirroring other studies that determined no regret of GnRHa administration or GAH [gender-affirming hormones] and GAS [gender assignment surgery].”

The topic of regret serves as a common thread within discussions of treatment outcomes in the cited literature and seems to profoundly influence considerations of eligibility for GAMT and decision-making processes. The possibility of regret is notably highlighted as a critical factor to be addressed to ensure the “effectiveness” of GAMT and feelings of regret are portrayed as “unfavorable,” indicating that the absence of regret is a “positive” result. Authors often seem to equate regret with detransition, portraying both as unambiguously “negative” outcomes, leaving little room for a more nuanced understanding of the diverse ways in which TGD individuals might experience (de)transition [ 30 , 80 , 83 ]. As such, the cited literature stresses minimizing regret as an essential aspect of ensuring the “effectiveness” of GAMT for adolescents.

In this article, we examined what constitutes “effective” GAMT treatment outcomes and how normative assumptions regarding GAMT for adolescents are reflected through these outcomes. Utilizing trans negativity as a theoretical lens, we conducted a theory-informed reflexive thematic analysis of the cited literature in the “Research Evidence” section of the SOC8 Adolescents chapter. Our primary goals were to (1) provide an overview of the treatment outcomes cited in the literature and (2) to elucidate the normative assumptions underlying these outcomes.

In total, we identified 44 different measures which were used to assess GAMT outcomes for adolescents (see Table  1 ). These measures cover a broad range of constructs, including gender dysphoria and body dissatisfaction, psychological functioning, global functioning, social functioning, quality of life, and satisfaction with care. Notably, many of these measures are used in only a single study, and authors themselves explained and interpreted the use of these measures in varying ways. Despite this overall lack of uniformity in outcome measures, psychological functioning was the most frequently assessed construct across these sources. This highlights the authors’ emphasis on “effective” treatment in terms of improved psychological functioning.

Our theory-informed reflexive thematic analysis revealed four main themes that underpin an “effective” GAMT trajectory and treatment outcomes: (1)  doing bad: experiencing distress before GAMT , (2)  moving toward a static gender identity and binary presentation , (3)  doing better: overall improvement after GAMT , and (4) the absence of regret . Ultimately, we found that the cited literature in the “Research Evidence” section of the SOC8 Adolescents chapter tends to portray GAMT as a process that generally follows a movement from “doing bad” to “doing better,” achieving a stable gender identity and avoiding post-treatment regret. Empirical evidence showing pre-transition distress along with physical, psychological, and/or psychosocial improvements post-GAMT, demonstrated through quantitative data, is used to support claims about the “effectiveness” of GAMT for adolescents.

Justifying the “effectiveness” of GAMT for adolescents: a logic of improvement

Taken together, the SOC8 positions these 16 sources as research evidence to justify the provision of GAMT for adolescents. Citing multiple studies [ 19 , 20 , 67 , 69 , 71 , 72 , 73 ], the authors of the SOC8 Adolescents chapter assert that “the data consistently demonstrate improved or stable psychological functioning, body image, and treatment satisfaction,” classifying these improvements as “ positive results of early medical treatment” (1 p46, emphasis added). Although they acknowledge the limitations of the existing studies, such as relatively small sample sizes and varying follow-up periods, they argue that the “emerging evidence base indicates a general improvement in the lives of transgender adolescents” (1 p47). Furthermore, they state that “the data show early medical intervention – as part of broader combined assessment and treatment approaches focused on gender dysphoria and general well-being – can be effective and helpful for many transgender adolescents seeking these treatments” (1 p47, emphasis added). Hence, the SOC8 authors use these “positive” empirical results to justify the provision of GAMT for adolescents.

The flip side of the above is that improvement has become a norm that GAMT is required to meet in order to be justified, often operationalized by measurable, beneficial effects on the overall well-being of TGD adolescents. However, our findings indicate ambiguity regarding the objectives of GAMT for adolescents. Should its primary aim be to alleviate gender-related distress, or the improvement of general well-being and functioning in order for it to be justified? While most of the sources cited in the SOC8 highlight the need for more research on GAMT for adolescents, it seems there is not yet consensus on how to evaluate its efficacy, as evidenced by the broad diversity of measures detailed in Table  1 .

Furthermore, the (implicit) normative expectation that GAMT should result in improvements across multiple physical, psychological, and psychosocial outcomes risks undermining the provision of this care practice. Indeed, critics often refer to the supposed failure of GAMC to result in improved psychological well-being and psychosocial functioning to question the validity of GAMT:

The significant rate of problematic adaptations, psychiatric symptoms, and self-harm in this youth cohort […] is explained away as merely manifestations of minority stress, with unsubstantiated claims that these mental health problems will resolve with gender transition—and only with gender transition ([ 84 ] p115).

Not all psychiatric and psychosocial problems in adolescents displaying gender dysphoria are secondary to gender identity issues and will not be relieved by medical gender reassignment. An adolescent’s gender identity concerns must not become a reason for failure to address all her/his other relevant problems in the usual way (60 p218).

These critiques have far-reaching policy consequences. As Amin [ 3 ] notes, legislators have used studies suggesting that GAMT shows insufficient psychological and psychosocial improvement as a basis to outlaw this care for minors. Consequently, research that concludes anything less than unequivocal “effectiveness” of GAMT risks providing critics of this care practice with “ammunition to attack trans medical care” ([ 85 ] p345). It is in this context that the force and constraint of the logic of improvement become apparent: “improvement” seems one of the only ways to justify this care practice for TGD adolescents, but comes at the cost of obscuring and rendering invisible more diverse and nuanced experiences of GAMT and risks discrediting this care practice. The latter has serious ethical implications for clinical practice and (shared) decision-making: the logic of improvement risks reproducing (largely implicit) normative images of “straightforward” presentations of gender dysphoria and “good functioning” clients as opposed to “complex” clients with co-occurring mental health problems whose experiences of gender dysphoria are perceived by care healthcare providers as unstable or less credible.

Not only does this logic limit space for more diverse and nuanced experiences, it can also put a strain on the therapeutic relationship between healthcare providers and TGD youth themselves [ 26 , 86 , 87 , 88 ]. For example, there is a prevalent fear among TGD individuals who want to access GAMT that not showing enough distress will impact their eligibility for care [ 26 , 87 , 88 ]. This places further tension on the provider-client relationship; TGD individuals may see their healthcare providers as gatekeepers, hindering honest communication due to a fear that it may jeopardize their care [ 25 , 86 ]. This medical model can function to push healthcare providers into the role of gatekeepers, who are then expected to navigate the inherent uncertainty involved in this care and prevent any risk of regret [ 25 ].

Furthermore, challenging the logic of improvement has significant clinical implications. For example, it becomes imperative for healthcare providers to engage in open conversations with TGD individuals and their families or caregivers about the possibility that GAMT may not lead to the expected or desired outcomes. As discussed earlier, this narrative of transition as “curative” is not limited to medical settings; it is also prevalent within TGD communities. However, framing GAMT as entirely curative may impose unrealistic expectations on both the treatment itself as well as healthcare providers to deliver exclusively “positive” outcomes [ 30 , 80 ]. Openly addressing and accepting the wide range of potential developments and treatment outcomes – including changes in the individual’s gender identity, treatment preferences, regret, and the possibility of retransition or detransition – will foster a more nuanced and diverse understanding of GAMT, helping TGD youth, their parents or caregivers, and healthcare providers to make well-informed decisions. Taking this approach to GAMT not only relieves the pressure on this form of care to “fix” several aspects of a person’s life but also allows for a more nuanced and realistic understanding of the “effectiveness” of GAMT.

Moving beyond the logic of improvement

While some cited articles in the SOC8 Adolescents chapter acknowledge that GAMT alone may not lead to improvement in overall well-being and functioning, the prevailing literature implicitly assumes that GAMT is “effective” and justified when a stable gender identity is attained and psychological well-being and psychosocial functioning improve. The teleological nature of this narrative is inherent in the logic of improvement and suggests that there is a measurable endpoint in which GAMT has been “effective” for the individual. The literature cited in the SOC8 Adolescents chapter generally frames TGD adolescents’ lives before GAMT as marked by distress and intense psychological suffering and life after GAMT as characterized by improvement across physical, psychological, and psychosocial registers.

However, this teleological account of transition – resulting in alignment between one’s gender identity and body, alongside improved well-being – risks oversimplifying the often complex and ambivalent experiences of gender transition into a linear narrative of improvement; the expectation that this care could address all aspects of general functioning and well-being is unrealistic. Further, this expectation of gender transition as a step-by-step linear process can harm those undergoing treatment, creating external pressure to follow a specified trajectory [ 30 , 80 , 83 ]. While GAMT often aids in achieving gender congruence and overall improvement, benefiting the lives of young TGD individuals, the justification of this care practice should not be conditional on this logic of improvement. Trans negativity [ 1 , 2 , 3 , 89 ] challenges the dominant discourse that GAMT must necessarily alleviate distress and lead to improvement in overall well-being and functioning in order to be justified, instead acknowledging that negative feelings often persist after, or even because of, GAMT. As Malatino (4 p26) states, trans negativity challenges the dominant framing of GAMT characterized by a period of distress, followed by an “experience of harmony, good feeling, corporeal comfort, and ease when navigating everyday social interactions.”

In other words, while narratives of improvement can function to justify GAMT, they risk excluding more nuanced and complex experiences. Trans scholars argue that experiences of GAMT are often messier, more ambivalent, and temporally more complex than the binary of “doing bad before GAMT” and “doing better after GAMT” [ 90 , 91 , 92 ]. For example, Chu (2 np) notes, “I feel demonstrably worse since I started on hormones,” and mentions increased suicidal ideation after GAMT. Despite feeling worse during her transition, Chu (2 np) states, “transition doesn’t have to make me happy for me to want it [...] Desire and happiness are independent agents.” Consequently, Chu (2 np) argues that the only prerequisite for GAMT should be a demonstration of desire, asserting that “no amount of pain, anticipated or continuing, justifies its withholding” and that GAMT cannot be expected to “maximize good outcomes.” Chu’s perspective contributes an alternative for moving beyond the logic of improvement narrative, and therefore beyond diagnostic prerequisites and “effective” treatment outcomes. Footnote 10 In a similar vein, Amin [ 3 ] challenges the normative notion that individuals undergoing GAMT should aspire to happiness and that GAMT inherently leads to this outcome, instead asserting that gender transition should not be expected to eliminate all negative feelings. Rather, negative affective states, such as the experience of regret, are inherent to all lives, including those of TGD individuals [ 1 , 2 , 3 ]. As Malatino states, “transitioning doesn’t have to be wholly curative, or even minimally happy-making, in order for it to be imperative” (4 p3).

Strengths and limitations

Regarding our methodology, it is important to note the strengths and limitations of our work. A strength of our approach is the use of trans negativity as a theoretical lens. Trans studies and biomedical sciences have traditionally existed in separate spheres, limiting the integration of nuanced understandings of GAMT into transgender healthcare. Trans studies broadly, and theorizations of trans negativity specifically, offer a valuable perspective for reimagining transgender healthcare and fostering more nuanced discussions. Our approach of reflexive thematic analysis is inherently subjective; we value moving away from claiming a “neutral” position in this field, making explicit our subjectivities and the positionalities that inform this work. While we believe our positionalities enhanced our analysis, we acknowledge that we potentially missed nuances in the data due to our deductive thematic approach.

While GAMT does often aid in achieving gender congruence and overall improvement, benefiting the lives of young TGD individuals, engaging with trans negativity as a theoretical lens emphasizes that negative feelings can persist post-GAMT. This perspective encourages critical reflection on the normative assumption that GAMT must inevitably lead to “positive” outcomes to justify its provision. Instead of solely focusing on substantiating the “effectiveness” of GAMT with empirical evidence and justifying its provision by showing overall improvement, we should explore how to better support healthcare providers and TGD individuals in navigating negative feelings throughout and post-GAMT. Allowing space for these complex experiences, rather than trying to avoid or mask them, could offer relief for both healthcare providers and TGD adolescents and foster a more honest care environment.

However, questioning the current operationalization of “effectiveness” in GAMT for adolescents raises a critical question: if GAMT does not necessarily require demonstrating improvement to justify its provision, what should its objectives be? In other words, what ethical and philosophical justifications should underpin GAMT for adolescents, and what does good GAMT for adolescents entail? As we have seen, the treatment outcomes presented in the SOC8 “Research Evidence” section of the Adolescents chapter primarily rely on the ethical principles of beneficence and non-maleficence, with the provision of GAMT largely justified by empirical outcomes demonstrating its “effectiveness.” Others have proposed alternative ethical frameworks for justifying the provision of GAMT for adolescents; for example, by drawing an analogy to interventions like abortion and birth control [ 9 ]. Similar to GAMT, these interventions alter healthy physiological states based on an individual’s fundamental self-conception and desired life path, with their effectiveness measured by how well they help individuals achieve their embodiment goals [ 9 ]. In this view, healthcare is provided and justified on the basis of personal desire and autonomy.

While we do not propose a definitive answer to this complex question, we aim to initiate a normative discussion on how the “effectiveness” of GAMT for adolescents should be assessed. One promising approach to achieve this is through participatory action research, which involves TGD youth in the research process to better understand what they find important regarding GAMT and its outcomes [ 93 , 94 ]. Participatory action research, which has been employed in other areas of medical research, is considered particularly valuable for building community ties and addressing power imbalances within research [ 95 ]. While it is important to acknowledge that TGD youths’ preferred outcomes are not monolithic – participatory action research will not yield a single specific outcome to assess the “effectiveness” GAMT – it will provide a more truthful understanding of what matters to TGD adolescents, facilitating conversations about GAMT with youth and supporting healthcare providers and clients in (shared) decision-making.

Data availability

No datasets were generated or analysed during the current study.

We acknowledge that the use of various terms in this context, such as gender-affirming medical treatment versus gender-affirming medical care , can have different implications. Throughout this article, we use the term “gender-affirming medical treatment” (GAMT), to remain consistent with the current terminology used by WPATH and throughout the SOC8 [ 35 , 96 ]. While an examination of the distinctions and nuances in the utilization of GAMC and GAMT would be worthwhile, such an analysis extends beyond the scope of this article.

In this article, we use TGD as an umbrella term referring to various forms of gender identities, roles, and expressions of and relations to gender that are different from those normatively expected of one’s assigned sex at birth.

The eligibility criteria for GAMT interventions have been widely critiqued by various scholars (e.g., [ 45 , 97 , 98 ]) for gatekeeping GAMT for TGD individuals. Critics argue that these criteria impose unnecessary barriers, restrict access to essential medical treatments, and undermine the self-determination of TGD individuals by subjecting them to extensive psychological evaluations.

The SOC8 was developed by a committee of 119 experts from a variety of disciplines and with diverse backgrounds. In order to determine the final version of the SOC8, the committee employed a Delphi technique in combination with existing scientific evidence [ 35 ].

Some articles employ outdated, inappropriate language to refer to TGD individuals and elements of GAMT. While we made efforts to exclude harmful language whenever possible, we maintain the original terminology when quoting these sources.

We recognize how drawing a distinction between these terms can be problematized [ 73 , 76 , 77 ] and acknowledge that using ‘trans’ and ‘queer’ as standalone categories undermines their intended purpose.

In the diagnosis of gender incongruence [ 44 ], the defining element of distress in order to access GAMT is removed, instead emphasizing the incongruence rather than the potential distress it may cause. In line with this, the SOC8 now recommends using the diagnosis of gender incongruence to facilitate access to GAMT [ 35 ]. However, in practice, gender dysphoria, accompanied by a narrative of distress, remains prevalent in clinical settings and continues to influence eligibility for GAMT.

It is important to note that some of the studies referenced in the “Research Section” in the SOC8 Adolescents chapter were conducted at a time when concepts such as gender fluidity and non-binariness were not recognized or considered in research, especially in Cohen-Kettenis and Van Goozen [ 64 ] and Smith et al. [ 29 , 68 ]. As a result, the utilized scales and discussed outcomes predominantly reflect a binary understanding of gender.

Most authors do not mention race. Some mention it as a demographic [ 20 , 66 , 67 , 72 , 73 , 75 ]. Only Tordoff et al. [ 72 ] discuss considering it as a covariate, while none of the studies discuss it in depth. However, race and gender are deeply intertwined and influence societal expectations and perceptions of gender.

See also [ 9 , 99 ].

Abbreviations

• Gender-affirming medical treatment

Trans and gender diverse

Standards of Care

World Professional Association for Transgender Health

Gender dysphoria

Body Image Scale

Utrecht Gender Dysphoria Scale

Gender-affirming hormones

Gonadotropin releasing-hormone analogues

Testosterone

Cross-sex hormones

Transition-related medical interventions

Transition-related care

Male-to-female

Sex reassignment

Sex reassignment surgery

Gender reassignment surgery

Gender assignment surgery

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Acknowledgements

We would like to thank the anonymous reviewers for their valuable feedback and insightful suggestions, which have greatly improved this article.

This article is funded by the Dutch Organization for knowledge and innovation in health, healthcare and well-being (ZonMw): 09150172110101 and the European Union (ERC-StG 101042028). Views and opinions expressed are however those of the authors only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible for them.

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Ezra D. Oosthoek and Skye Stanwich contributed equally to this work.

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Center of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Vrije Universiteit, De Boelelaan 1118, Amsterdam, 1081 HZ, The Netherlands

Ezra D. Oosthoek, Skye Stanwich, Karl Gerritse, David Matthew Doyle & Annelou L.C. de Vries

Department of Child and Adolescent Psychiatry, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1118, Amsterdam, 1081 HZ, The Netherlands

Ezra D. Oosthoek, Skye Stanwich, Karl Gerritse & Annelou L.C. de Vries

Department of Medical Psychology, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1118, Amsterdam, 1081 HZ, The Netherlands

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Oosthoek, E.D., Stanwich, S., Gerritse, K. et al. Gender-affirming medical treatment for adolescents: a critical reflection on “effective” treatment outcomes. BMC Med Ethics 25 , 154 (2024). https://doi.org/10.1186/s12910-024-01143-8

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Received : 23 June 2024

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Gender dysphoria: Quality of online information for gender reassignment surgery

Federico lo torto, francesco rocco mori, edoardo bruno, giorgio giacomini, gianmarco turriziani, guido firmani, marco marcasciano, diego ribuffo.

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Corresponding author at: Department of Surgery ‘‘P.Valdoni’’, Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, via dei Latini 33, 00185 Rome, Italy. [email protected]

Received 2023 Jul 18; Accepted 2023 Aug 27; Collection date 2023 Dec.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

An ever-increasing number of patients are using the Internet to learn about medical conditions. This study aimed to evaluate the quality of Internet-based patient information on gender reassignment surgery for people who suffer from gender dysphoria.

Twenty websites identified using Google and Yahoo search engines were selected and evaluated based on the modified Ensuring Quality Information for Patients (EQIP) instrument (36 items).

The EQIP tool comprises 36 questions to which the answer can be “yes” or “no”. The final score for each website can be between 0 and 36. An overall score of 26 or above was considered high, because it co-related to the 72nd percentile. The average of the scores turned out to be 22.5 points, lower than our target; 7 (35%) sites were rated higher than the average and 13 (65%) were rated lower.

The assessment of the websites included in the study showed a lack of information about the sequence of the medical procedures, perioperative criticalities and qualitative risks and side-effects descriptions. The overall quality of published information on gender reassignment surgery is very low. We believe that the Internet should not be used as the main source of medical information, and physicians should maintain the leadership in guiding patients affected by gender dysphoria.

Level of Evidence: Level IV, case study.

Keywords: Gender dysphoria, EQIP Tool, Online information, Gender reassignment surgery

Introduction

Patients who suffer from gender dysphoria experience a discrepancy between their birth gender and the basic sense of self as a man or a woman (a person's gender identity), which causes them an internal conflict. 1 They feel constant disquiet with their anatomical sex, they believe they were born of the wrong sex 2 and use the opposite gender role. 3

To date, the prevalence of gender dysphoria is estimated to be up to 1.3 percent of the world population 4 , 5 , 6 and the incidence is one in every 60.000 people, with a four times higher frequency of male-to-female transsexuals than female-to-male transsexuals. 7 , 8 , 9

The term “Transsexualism” appeared for the first time in the Diagnostic Psychiatric Manual and Statistical Manual of Mental Disorders, Third Edition, in 1980; in the Fourth Edition, the term was dropped because it was starting to be considered a purely sexual disorder instead of a gender identity disorder. 2

The etiopathogenesis of gender dysphoria is still unknown and further studies are needed. Still, currently, some theories define social and external psychological factors as the cause of gender identity disorder, whereas other studies emphasise the role of biological factors. These studies can be categorised into three groups. The first group claims that hormonal abnormalities such as androgen resistance or adrenal hyperplasia have a role in gender identity disorders. The second category of studies associates gender identity disorders with anomalies in the secretion of gonadotropins. The third, conducted since the mid-1990s, supports the role of sexual morphological differentiation of the brain. The main argumentation used to support this theory is based on the analysis of the volume of the central subdivision in the bed nucleus of the stria terminalis (BNST) - a part of the brain involved in sexual behaviour—which is usually larger in men, than in women. The theory was based on the fact that female-sized BNST was found in male-to-female transsexual individuals. 10 , 11 , 12 , 13 , 14

It is widely demonstrated in the literature that the best way to assist individuals with severe forms of gender dysphoria is to perform gender reassignment surgery, which is defined as the whole genital, facial and body surgical procedures required to create an opposite gender appearance. 15 , 16

The study aims to evaluate the quality of information accessible on the Web about gender reassignment surgery through a validated method for the critical analysis of the quality of health information, the modified Ensuring Quality Information for Patients (EQIP) instrument. 17 , 18 The EQIP scale has also been employed in other studies, demonstrating its effectiveness in evaluating the information available online about other fields of plastic surgery. 19 , 20 , 21

Materials and methods

Google and Yahoo are the most commonly used search engines worldwide. The following keywords were used in those search engines to perform our study: “Gender” AND “reassignment” AND “surgery”. The first 50 webpages shown with the online search results were included. The following exclusion criteria were used: unsuitable content such as duplicates, blogs, and peer review papers. The webpages that accomplished the inclusion criteria were grouped into five units (practitioners, hospitals, healthcare portals, professional societies, and encyclopaedias) and were assessed using the expanded EQIP scale. The EQIP scale is a questionnaire consisting of 36 questions divided into three sections: content (items 1-18), identification data (items 19-24) and structure (items 25-36) and canonically be answered with “YES” or “NO” for each item. Contents of the data section feature, for example, questions about the definition of which subjects will be covered, the description of alternative treatments (including no treatment at all), the description of the safety measures that the patients must undertake, qualitative and quantitative benefits and risks, and the sequence of the surgery. In this scale, “Qualitative benefits/risks” refers to risk–benefit ratio related to the procedures, such as feeling comfortable with the new body image or common complications. “Quantitative benefits/risks” refers to if we find statistical analysis and values about benefits or risks. Another section is called “identification data”, with questions regarding who financed or produced the webpage and if there is a logo, date of production, or a references to support the reported data. The last section attempts to determine whether the written information is understandable by each user and whether the layout and digital content are pertinent and suitable. Each positive answer to each question is worth 1 point, whereas a negative answer warrants no points. A score is attributed to each website, ranging from a minimum of 0 to a maximum of 36. With 26 or more points, equivalent to the 72 nd percentile, the website was considered a high score. Fewer than 26 points defined a low score.

Our study conducted a search on Google and Yahoo as search engines. After implementing the inclusion mentioned above and exclusion criteria, 20 qualified webpages were selected as appropriate for this research. We found three practitioners’ websites (15%), two hospital websites (10%), seven healthcare portals (35%), seven professional societies websites (35%) and one Encyclopaedia (5%). The expanded EQIP tool was chosen to assess those websites using qualitative and quantitative methods.

We considered an overall score of 26 or above a high score and found that the mean score was 22.5 points, dramatically lower than our target score. Overall, seven websites (35%) with a high score and 13 (65%) with a low score ( Table 1 ). Practitioners’ websites had a mean score of 23 points, hospitals of 19,5 points, healthcare portals of 19,1, Professional societies of 20 points and Encyclopaedia of 22 points. When considering the weighted average, a similar trend was obtained.

EQIP tool results applied to the 20 eligible websites about “Gender reassignment surgery” research on Google Ⓡ and Yahoo Ⓡ .

Healthcare portals and Hospital webpages obtained the worst scores. Both groups represented most of the results in the first 50 hits on the search engines. Conversely, practitioners’ websites achieved the highest mean score, though they were only three (15%) among total hits, approximately half of all high-scored Web pages. In the results of content data, the sequence of the procedures, quantitative benefits, side effects and risk had the worst descriptions, which led to the lowest scores.

There was a deficiency regarding how potential complications would be dealt with and the alert signs that a patient might detect. Only two websites included all the appropriate themes of the topic. In detail, analysing identification data, we noticed all the websites reported a logo and most specified the revision date (85%). Only three websites (15%) reported references to evidence-based data used. Regarding the Structure data analysis, we observed that the language used was clear, understandable, with a respectful tone and use of everyday language. There was no balance among benefits and risk (only for 35%) and no websites included a consent form, but almost all the websites presented a good layout (75%) and appropriate digital content.

Gender dysphoria is nowadays considered a well-defined and discussed health impairment. 4 , 5 , 6 The problem of the discrepancy between gender identity and gender assigned at birth requires complex management. To take care of transgender individuals, a multidisciplinary approach is needed through medical, surgical, psychological and social support. The burden of psychological involvement is very high for transgender patients and clinicians have to consider this aspect. Current evidence has demonstrated that Gender identity conversion efforts are harmful, increasing the risk of adverse mental health outcomes in adulthood and suicide attempts among youth. 22 , 23

Conversely, gender-affirming surgery has been associated with improved mental health outcomes, highlighting the strong correlation between providing gender-affirming surgery and psychological benefits for transgender people. 24 , 25 Sex reassignment surgery plays a central role in establishing the harmony between body and self-identity. To achieve this goal, plastic surgeons perform a wide range of procedures. The transition is developed both through gender confirmation surgery (vaginoplasty or phalloplasty) and body contouring interventions, such as mastectomy or mammoplasty and other minor procedures. All these efforts are made to reach the target of restoring healthy psychological and physical harmony.

In modern society, the main source of information is the Internet. It is estimated that health-related websites are around 20,000 to 100,000 and patients are used to search the Internet for information regarding their conditions. 26 , 27 Hence, patients affected by gender dysphoria can also find many inputs related to their clinical condition and surgical solutions on the Web. We believe this phenomenon can be dangerous if the sources used are unreliable . An interesting phenomenon is the variation of trends searched on Google or Yahoo after public announcements made by celebrities about their medical conditions. 28 Our study was stimulated by the need to prove and examine the quality of information related to this theme and its related therapeutic surgery. We used the EQIP scale to analyse various aspects of 20 medical Web pages by rating the accuracy of the data provided. The broad use of the Web as a source of medical knowledge leads the patients to be wrongly well- and self-informed before the consultation with clinicians. However, the quality of this knowledge has to be thoroughly evaluated.

We found that an enormous number of sources is rarely related to a good level of the offered information, especially for pages from hospitals and healthcare portals. Practitioners’ websites, instead, scored the highest for the reliability of the data provided, but there were only a few among all sites examined. Indeed, our work highlighted a critical lack of qualitative data supplied, despite the huge quantity of content. We discovered a dramatic absence of the procedure's description, risks and side effects, with a shortage of precautions that patients should take (it was reported in only 10% of sites). Furthermore, the constant lack of evidence-based references and the date of revision (absent in 15%) weakens the strength of the data provided.

It can be useful for clinicians involved in managing this complex pathology to be aware of the data available on the Web. Their knowledge is useful to understand the quality of information that patients can find on the Internet, to prevent any misapprehension.

Gender reassignment surgery may improve the quality of life, but it has its intrinsic risks. All surgical interventions are related to a variable number of complications, the most feared and demanding ones are related to the neo-urethra creation, ranging from 4 to 50%, especially in male-to-female surgery. 26 , 27 Postoperative functional or aesthetic complications are common side effects, including vaginal stenosis, infections, and perineal muscle hyperspasticity, sometimes requiring secondary revision surgery. 29 Moreover, all the well-known complications related to breast implants (infections, contracture, poor aesthetic outcome, exposure of prosthesis) and body contouring surgery in general should be considered. Finally, haemorrhagic complications, even requiring transfusion in up to 45% of cases, are dangerous and should be well understood by patients. 28 , 29 This large amount of side effects leads to a high rate of re-interventions.

The quality of information provided by the Web regarding gender reassignment surgery was not satisfactory. Healthcare portals and hospitals reported a lower score than practitioners’ websites, conversely achieving the best scores. This difference may be because this surgery is performed only in highly specialised centres and such procedures are not commonly performed.

As a result of our observations, we believe that the Internet should not be used as the main source of medical information, and physicians should maintain the role model, walking these patients through the intricacies of gender reassignment surgery. Therefore, the information on the Web has to be well-planned and reviewed by specialists. Reliable data, expressed through clear language, must be reported on online pages. Complications should be cited to provide complete knowledge. Only this way can it be possible to supply good quality information on the Web to support patients’ decisions and the correct Internet use.

Conflict of Interest

The authors declare no potential conflicts of interest regarding this article's research, authorship, and/or publication. The authors who have taken part in this study declare that they do not have any commercial associations that might pose or create a conflict of interest with the information presented in this article.

Acknowledgments

Ethical approval.

Not required.

Acknowledgement

The authors declare that they have no conflict of interest.

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Letter to the Editor

A New Perspective on Gender Dysphoria and Repetitive Sex Reassignment Surgeries: A Case Report

Parvaneh Ehsanzadeh, MD; Shakeel Raza, MD; and Zishan Haq, MS

Published: April 15, 2014

To the Editor: Gender identity disorder (GID), also known as gender dysphoria or transgender identity , refers to the experience of major dysphoria or dissatisfaction with the sex that individuals were assigned at birth and the gender responsibilities related to their sex. 1 , 2 Nationwide, stigma attached to transsexualism has made it a commonly shunned condition (with transsexualism also being a commonly shunned term) that can profoundly impact individuals’ lives, especially if left untreated. We present a unique case of repetitive sex reassignment surgeries from male to female and back again to male in a 28-year-old patient and discuss the outcomes.

Case report. A 28-year-old shy, depressed married man with a DSM-IV diagnosis of major depressive disorder was referred to a psychiatric lesbian, gay, bisexual, and transgender clinic and explained his sexual identity problem that had caused him depression, anxiety, and suicidal ideas and plans. Although he was married at age 20 years and had fathered 2 children, he was still struggling to be identified as a male. He described his desire to be a girl and how he used to dress up as a girl when he was 5 years old.

At the time of the visit, he had divorced his wife, had abandoned his children, and planned to marry his male lover and to live with him as his wife. He was conscious of the impact of his decision on others and was feeling guilty about abandoning his family to marry a male partner, but was unable to restrain himself from carrying out his plans.

The patient attended 20 hourly psychiatric sessions over 12 months before presenting to the clinic with no improvement. Further endocrinology evaluations and laboratory workups for hormonal imbalance revealed no abnormalities. He received 20 more hourly psychiatry sessions and cognitive therapy for 6 months with no improvement. He was then referred to urologists for additional evaluation for sex reassignment surgery, which was completed successfully.

However, the patient returned 10 years later with worsening anxiety and depression and suicidal ideas and plans. She stated how she had been married happily and enjoying life with her lover, yet she gradually started struggling with her gender as a female and the desire to switch back to a male. Her symptoms were so severe that she had twice attempted suicide to end her emotional pain.

She underwent concurrent psychiatric counseling and rehabilitation for 6 months with no improvement. The decision was made for her to be referred for sex reassignment surgery and hormone therapy, which were completed successfully and which were followed by significant improvement in the symptoms of depression, anxiety, and suicidal ideation at 6-month follow-up. There was no long-term follow-up on this patient and his fate.

There are no recently updated data on the prevalence of gender dysphoria. According to scant research, the prevalence of gender dysphoria is projected to be approximately 1 in 30,000, although this number is thought to significantly underestimate the true prevalence. To ensure quality of life, transgender individuals need professional medical and mental health care to transition from their birth sexual identity to their internal sense of gender. 3-5

Even if the number of gender dysphoric individuals is on the rise, there is little research regarding this population and their health care needs. Given the stigma surrounding this population, they are less likely to receive appropriate help, which can result in further mental and health turmoil.

On the other hand, there are individuals who self-identify as transgender and seek extensive interventions to satisfy their internal sense of gender. This group ends up changing their physical appearance frequently from one gender to another. Given the scope of the public health burden of unnecessary repetitive procedures, it is important to conduct more comprehensive studies on this population to make sure they receive appropriate treatment and to prevent unnecessary costs.

In conclusion, investigating gender dysphoria and the individuals’ transition over time can benefit the treatment of psychiatric disorders among transgender individuals. It is a responsibility of psychiatrists to explore the patient’s hidden motives behind change of gender to help that patient attain a greater inner relational freedom.

Parvaneh Ehsanzadeh, MD

[email protected]

Shakeel Raza, MD

Zishan Haq, MS

Author affiliations: Lone Star Behavioral Hospital, Tomball, Texas (Dr Ehsanzadeh); Department of Psychiatry, Immanuel Medical Center, Omaha, Nebraska (Dr Raza); and Department of Psychology, University of Houston, Houston, Texas (Mr Haq).

Potential conflicts of interest: None reported.

Funding/support: None reported.

Published online: March 20, 2014.

Prim Care Companion CNS Disord 2014;16(2): doi:10.4088/PCC.13l01608

© Copyright 2014 Physicians Postgraduate Press, Inc.

1. Kurahashi H, Watanabe M, Sugimoto M, et al. Testosterone replacement elevates the serum uric acid levels in patients with female to male gender identity disorder [published online ahead of print September 18, 2013]. Endocr J . PubMed doi:10.1507/endocrj.EJ13-0203

2. Schenck-Gustafsson K, DeCola PR, Pfaff D, et al. Handbook of Clinical Gender Medicine . Basel, Switzerland: Karger Verlag; 2012:328-330.

3. Conway L. How frequently does transsexualism occur? http://ai.eecs.umich.edu/people/conway/TS/TSprevalence.html Updated December 17, 2012. Accessed January 10, 2014.

4. Grigorovich A. Long-term care for older lesbian and bisexual women: an analysis of current research and policy. Soc Work Public Health . 2013;28(6):596-606. PubMed doi:10.1080/19371918.2011.593468

5. Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry , Ninth Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:305-306.

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The world is getting smaller and smaller. In Europe, borders are disintegrating and a joint currency (EURO) is already upon us. Globetrotters encounter the same companies, the same hotel chains, and the same fast food nearly everywhere they go. Some say the world is fast becoming a ‘global village’. And yet this ‘village’ is not governed by unanimity. Taking any sociopolitical topic at random, it is impossible to make a non-controversial statement about it. For every opinion there is a counter-opinion; for every attempt to solve a problem, a counter-attempt. Our opinions are divided on all matters of import, although our differences regarding the moral evaluation of (new) medical options are particularly marked. We have not even been able to achieve unanimity in individual countries (the villages within the global village), as the never-ending arguments about the permissibility of abortion, embryo research, germline interventions and euthanasia (to name but a few) aptly show. The reasons for this dissent are the profound anthropological differences and varying worldviews of the individual citizens at stake. Moral pluralism, as it is often termed, stems from the wars of religions and the Enlightenment, through which secular and religious communities have become mixed in many European states. Today we have to acknowledge the fact that there is a difference between society and (religious) community. There is no longer a single valid social stance acceptable to all (religious) communities, even in fundamental matters of human coexistence, even in the most fundamental of them all: the question of what constitutes being a man or a woman. Using the example of sex-reassignment surgery, the following paper will show that profound differences of opinion exist between individuals, (religious) communities and society about our understanding of males/females, and that there is a deep rupture between traditional and post-traditional understandings of the sex of a human being and its reassignment. The sex-reassignment surgery option requires individuals and individual communities to take a stance, which may range from ‘progressive’ to ‘conservative-orthodox’. The problem facing the State is how to succeed in providing a framework inside which such differing positions may be adopted side-by-side. The problem facing individual citizens is how to find orientation when forming their own opinions in a world which is becoming increasingly complex in its globality. One fixed point of orientation for many is the differentiation male/female: a parameter they believe to be both ‘natural’ and beyond debatable.

I am in deep debt to many who gave generously support to this article. In particular, I am especially grateful to Dr. Georg Bier, Office of the Catholic Bishop, Limburg, Germany; Prof. Dr. med. Michael Sohn, Department of Urology, Markus-Hospital, Frankfurt/M., Germany; and Prof. H.T. Engelhardt, Jr., M.D., Ph.D., Rice University, Houston, Texas. Special thanks to Sarah L. Kirkby (B.A. Hons.) and Christiane Hearne for all their work with the translation.

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Schmidt, K.W. (2002). Stabilizing or Changing Identity? The Ethical Problem of Sex Reassignment Surgery as a Conflict among the Individual, Community, and Society. In: Po-Wah, J.T.L. (eds) Cross-Cultural Perspectives on the (Im)Possibility of Global Bioethics. Philosophy of Medicine, vol 71. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-1195-1_14

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