How Gender Reassignment Surgery Works (Infographic)
Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:
Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.
An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.
A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.
People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.
Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.
The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).
Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.
Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.
The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.
Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.
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The Evidence for Trans Youth Gender-Affirming Medical Care
Research suggests gender-affirming medical care results in better mental health..
Posted January 24, 2022 | Reviewed by Abigail Fagan
- Sixteen studies to date have examined the impact of gender-affirming medical care for transgender youth.
- Existing evidence suggests that gender-affirming medical care results in favorable mental health outcomes.
- All major medical organizations oppose legislation that would ban gender-affirming medical care for transgender adolescents.
NOTE: This post was updated on October 11, 2022. In discussions of studies 5, 7, 8 and 10, the final sentence was appended to include further information about the study.
I'm a physician-scientist who studies the mental health of transgender and gender diverse youth. I also spend a lot of time on Twitter . And yes I know, that's my first mistake. I've noticed there seem to be hundreds if not thousands of Twitter accounts that will repeatedly post that there is no evidence that gender-affirming medical care results in good mental health outcomes for transgender youth.
Since several U.S. states are introducing legislation to outlaw gender-affirming medical care this year (despite opposition from just about every major medical organization including The American Medical Association, The American Academy of Pediatrics, and The American Psychiatric Association), I thought this was a good time to review the relevant research for you all. So buckle up — here we go. The studies are in chronological order. I'll provide a brief summary of each and provide the citation for people who want to read more. I'll plan on updating this post as new studies become available. As you read, please keep in mind that all studies have methodological strengths and weaknesses and conclusions must be drawn from all of these studies together.
Study 1: De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.
This study from the Netherlands followed 70 transgender adolescents and measured their mental health before and after pubertal suppression. Study participants had improvements in depression and global functioning following treatment. However, feelings of anxiety and anger , gender dysphoria , and body satisfaction did not change.
Study 2: De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.
Another study from the Netherlands. This one followed 55 transgender adolescents through pubertal suppression, gender-affirming hormone treatment ( estrogen or testosterone ), and gender-affirming genital surgery (as adults). Of note, many of these participants were also participants in study 1 (this study followed them for longer). The researchers found that psychological functioning steadily improved over the course of the study and by adulthood these now young adults had global functioning scores similar to or better than age-matched peers in the general population. Of note, one patient in this study died from a surgical complication of vaginoplasty (necrotizing fasciitis), but little additional information is provided.
Study 3: Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206-2214.
This study is from the United Kingdom. They followed 101 adolescents who received pubertal suppression at the beginning of the study and 100 adolescents who, for a range of reasons, were deemed by the team not ready to start pubertal suppression and thus did not receive it over the course of the study. Both groups received supportive psychotherapy . Both groups saw improvement in mental health. While the pubertal suppression group had a 5-point higher mean score on the study's psychological functioning scale at the end of the study, the difference was not statistically significant. This could have been due to the small sample size by the end of the study (the researchers only had data from 36 participants in the therapy-only group and 35 participants in the pubertal suppression group at the final time point of the study). We will see that later studies were able to obtain larger sample sizes so that statistically significant differences between those who did and did not receive pubertal suppression could be detected.
Study 4: Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.
This study was from researchers at Children's Mercy Hospital Gender Pathway Services Clinic in Missouri. They followed 47 transgender adolescents who received gender-affirming hormones (estrogen or testosterone) to a mean 349 days after starting treatment. They found statistically significant increases in general well-being and a statistically significant decrease in suicidality. Of note, the adolescents also received psychotherapy.
Study 5: Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213-219.
This study is from Finland. Researchers conducted a retrospective chart review of 52 adolescents who received gender-affirming hormones (estrogen or testosterone) and found statistically significant decreases in need for specialist level psychiatric treatment for depression (decreased from 54% to 15%), anxiety (decreased from 48% to 15%), and suicidality or self-harm (decreased from 35% to 4%) following treatment. However, the authors note that gender reassignment is "not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria."
Study 6: de Lara, D. L., Rodríguez, O. P., Flores, I. C., Masa, J. L. P., Campos-Muñoz, L., Hernández, M. C., & Amador, J. T. R. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41-48.
This study is from Spain. It followed 23 transgender adolescents who received gender-affirming hormones (estrogen or testosterone) and 30 cisgender controls for approximately one year. They found the transgender adolescents at baseline had worse measures of mental health than the cisgender control adolescents but that this difference equalized by the end of the study. The transgender adolescents in the study who received gender-affirming hormones had statistically significant improvements in several mental health measures, including anxiety and depression.
Study 7: van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.
This was another Dutch study, with an impressive sample size. Researchers compared 272 transgender adolescents referred to the gender clinic who had not yet received pubertal suppression with 178 transgender adolescents who had received pubertal suppression. They found those who received pubertal suppression had better mental health outcomes than those who did not receive pubertal suppression. However, because subjects received psychotherapy, the authors note that the study does not provide "direct evidence" that pubertal suppression improves mental health in transgender youth.
Study 8: Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.
This study was from Stony Brook Children's Hospital in New York. It followed 50 transgender adolescents longitudinally. Over the course of the study, 23 received pubertal suppression only, 35 received gender-affirming hormones only, and 11 received both. Three participants received no gender-affirming medical interventions. Over the course of the study, there was a statistically significant decrease in depression scores in one group: Male-to-female transitioners who underwent puberty suppression only.
Study 9: Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).
This study was from a gender clinic in Dallas, Texas. The researchers followed 148 transgender adolescents who were receiving gender-affirming medical treatment. 25 received pubertal suppression only, 93 received gender-affirming hormones (estrogen or testosterone) only, and 30 received both. 15 participants received gender-affirming chest surgery. When examining all participants together, the study found statistically significant improvements in body dissatisfaction, depressive symptoms, and anxiety symptoms.
Study 10: Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).
This study was conducted by myself along with several other researchers from Harvard Medical School. It utilized data from a non-probability sample of 20,619 transgender adults who reported ever wanting pubertal suppression. Of these, 89 actually received pubertal suppression. After adjusting for potentially confounding variables , access to pubertal suppression was associated with a lower odds of lifetime suicidal ideation. Of note, this study did not identify psychotherapy as a potentially confounding variable.
Study 11: Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., ... & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One, 16(2), e0243894.
This is another study from the United Kingdom. Researchers presented data for transgender adolescents who had received pubertal suppression. They had data for 44 patients after 12 months of treatment, 24 patients after 24 months of treatment, and 14 patients after 36 months of treatment. They were unable to detect any changes on their mental health measures (positive or negative).
Study 12: Grannis, C., Leibowitz, S. F., Gahn, S., Nahata, L., Morningstar, M., Mattson, W. I., ... & Nelson, E. E. (2021). Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology, 132, 105358.
This study recruited 42 birth-assigned female adolescents from a gender clinic in Ohio. Nineteen were receiving testosterone and 23 were not. Those not receiving testosterone were not receiving it due to a number of reasons (referred to endocrinology but hadn't started, parents not providing consent, and one was not interested in testosterone). The adolescents who were receiving testosterone treatment had lower scores on measures of generalized anxiety, social anxiety , depression, and body image dissatisfaction.
Study 13: Hisle-Gorman, E., Schvey, N. A., Adirim, T. A., Rayne, A. K., Susi, A., Roberts, T. A., & Klein, D. A. (2021). Mental healthcare utilization of transgender youth before and after affirming treatment. The Journal of Sexual Medicine, 18(8), 1444-1454.
This study utilized military healthcare data from transgender youth who received medical care through the U.S. military healthcare system. The researchers identified 963 transgender adolescents who had received some form of gender-affirming medical treatment. The mean age of starting any gender-affirming medical care was 18.2 (so this study may not technically qualify for our review of studies of adolescents). Their outcomes of interest were number of mental healthcare visits after gender-affirming medical care and number of days taking a psychiatric medication after starting gender-affirming medical care. In their adjusted models, there was no change in number of annual mental healthcare visits and an increase in days taking psychiatric medication from a mean 120 days per year to a mean 212 days per year. It's difficult to make firm conclusions based on this study, given the unusual outcome measure of number of days per year taking a psychiatric medication. The authors present a range of possible interpretations in the discussion section of the manuscript for those who are interested.
Study 14: Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2021). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health.
This study was conducted by researchers from The Trevor Project. They recruited 5,753 transgender adolescents who said they wanted gender-affirming hormone treatment (estrogen or testosterone). Of these, 1,216 had accessed gender-affirming hormones treatment. To focus on the results for only participants who were under 18: After adjusting for potential confounding variables, access to gender-affirming hormones was associated with lower odds of recent depression and suicide attempts when compared to those who desired but did not access gender-affirming hormones.
Study 15: Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One, 17(1), e0261039.
This study was also conducted by me and other researchers at Harvard Medical School. We examined 21,598 adults who reported ever desiring gender-affirming hormones (estrogen or testosterone). Of these, 481 accessed gender-affirming hormones during adolescence, 12,257 accessed gender-affirming hormones as adults, and 8,860 were never able to access gender-affirming hormones. We found that regardless of age of initiation, accessing gender-affirming hormones was associated with lower odds of past-year suicidal ideation and past year severe psychological distress. We also found that access to gender-affirming hormones during adolescence was associated with a lower odds of these same adverse mental health outcomes when compared to not accessing gender-affirming hormones until adulthood. Because the study was cross-sectional, we created a variable for people who had suicidal ideation in the past but did not have it in the past year (a proxy for mental health improving over time). We found that people who accessed gender-affirming hormones were more likely to meet this criterion than people who desired but did not access gender-affirming hormones, arguing against reverse causation (a common problem with cross-sectional studies).
Study 16: Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022) Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2), e220978.
This study was a prospective cohort study from Seattle Children's Gender Clinic. The researchers followed 104 transgender and non-binary youth who were receiving gender-affirming medical treatment. After adjusting for temporal trends and potential confounders, they found lower odds of depression and suicidality among young people who had started gender-affirming medical care, when compared to those who did not.
No Randomized Controlled Trials
One will notice that there have not been any randomized controlled trials. There is a general consensus in the field that such a trial would be unethical given the body of literature we have so far indicating that those in the control group would be likely to suffer adverse mental health outcomes compared to those randomized to the treatment groups. For this reason, it appears that no institutional review board would approve a randomized controlled trial at this time, under the principle of "equipoise" to which some bioethicists refer.
In summary, there have been, to my knowledge, 16 studies to date studying the impact of gender-affirming medical care for transgender adolescents. Taken together, the body of research indicates that these interventions result in favorable mental health outcomes. I will continue to update this post as new studies become available. Please feel free to contact me if you are aware of any new studies I have not yet included.
De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.
De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.
Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206-2214.
Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.
Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213-219.
de Lara, D. L., Rodríguez, O. P., Flores, I. C., Masa, J. L. P., Campos-Muñoz, L., Hernández, M. C., & Amador, J. T. R. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41-48.
van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.
Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.
Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).
Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).
Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., ... & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One, 16(2), e0243894.
Grannis, C., Leibowitz, S. F., Gahn, S., Nahata, L., Morningstar, M., Mattson, W. I., ... & Nelson, E. E. (2021). Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology, 132, 105358.
Hisle-Gorman, E., Schvey, N. A., Adirim, T. A., Rayne, A. K., Susi, A., Roberts, T. A., & Klein, D. A. (2021). Mental healthcare utilization of transgender youth before and after affirming treatment. The Journal of Sexual Medicine, 18(8), 1444-1454.
Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2021). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health.
Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One, 17(1), e0261039.
Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022) Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2), e220978.
Jack Turban MD MHS is a writer and fellow in child and adolescent psychiatry at Stanford University School of Medicine, where he researches the mental health of transgender and gender diverse youth.
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Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies
Sasha karan narayan.
1 Department of Surgery, Oregon Health and Science University, Portland, OR, USA;
2 Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA;
3 Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA;
4 Transgender Health Program, Oregon Health & Science University, Portland, OR, USA;
5 Primary Care, Equi Institute, Portland, OR, USA;
6 NYU Langone Health, New York, NY, USA;
7 University of Minnesota, Minneapolis, MN, USA;
8 Callen-Lorde Community Health Center, New York, NY, USA;
9 The University of Illinois at Chicago, Chicago, IL, USA;
10 Rush University Medical Center, Chicago, IL, USA;
11 The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA;
Jens Urs Berli
12 Division of Plastic & Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA
A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons’ experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.
This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.
The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.
In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.
Over the past several years, there has been sustained growth in institutional and social support for transgender and gender non-conforming (TGNC) care, including gender-affirming surgery (GAS) ( 1 ). The American Society of Plastic Surgeons (ASPS) estimates that in 2016, no less than 3,200 gender-affirming surgeries were performed by ASPS surgeons. This represents a 20% increase over 2015 ( 2 ) and may be partially attributable to an increase in third party coverage ( 3 , 4 ). A rare, but consequential, risk of GAS is post-operative regret that could lead to requests for surgical reversal. As the number of patients seeking surgery increases, the absolute number of patients who experience regret is also likely to increase. While access to gender-affirming health care has expanded, these gains are under continued threat by various independent organizations, religious, and political groups that are questioning the legitimacy of this aspect of healthcare despite an ever-growing body of scientific literature supporting the medical necessity of many surgical and non-surgical affirming interventions. It is therefore not surprising that studies on regret and surgical reversal are scarce compared to studies on satisfaction and patient-reported outcomes. The transgender community rightfully fears that studies on this topic can be miscited to undermine the right to access to healthcare.
The goal of this study is to assist patients, professionals, and policy makers regarding this important, albeit rare, occurrence. We do so by addressing the following:
- The current literature regarding the etiology of regret following gender-affirming surgery;
- The experience of surgeons regarding requests for surgical reversal.
Based on these results, the authors propose a classification system for both type and etiology of regret.
It is important to acknowledge that the authors identify along the gender spectrum and are experts in the field of transgender health (mental health, primary care, and surgery). We hope to facilitate discussion regarding this multifaceted and complex topic to provide a stepping-stone for future scientific discussion and guideline development. Our ultimate goal is to reduce the possibility of regret and provide clinical support to patients suffering from the sequelae of regret. We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-6204 ).
A 16-question survey (see Table S1 ) was developed and uploaded to the online survey platform SurveyMonkey (SurveyMonkey, Inc., San Mateo, CA, USA). This anonymous survey was e-mailed by the senior author to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. There were no incentives offered for completing this survey. One reminder e-mail was sent after the initial invitation.
Respondents were asked to describe their practices, including: country of practice, years in practice, a range estimate of the total number of TGNC patients surgically treated, and the number of TGNC patients seen in consultation who expressed regret and a desire to reverse or remove the gendered aspects of a previous gender-affirming surgery. We limited the questions to breast and genital procedures only. Facial surgery was excluded as there are no associated WPATH criteria, so there is less standardization of patient selection for surgery. Thus, we did not feel that those patients should be pooled with those who were subject to WPATH criteria in our calculation for prevalence of regret. We did not define the term “regret” in order to capture a wide range of responses. Respondents were asked about their patients’ gender-identification, the patient’s surgical transition history, and the patient’s reasons for requesting reversal surgery. If the respondents had experience with patients seeking reversal surgery, the number of such interventions were queried to include: the initial gender-affirming procedure and the patients’ reason(s) for requesting reversal procedures. The respondents were also asked about the number of reversal procedures they had performed, and what requirements, if any, they would/did have prior to performing such procedures. Finally, respondents were asked whether they believed that the WPATH Standards of Care 8 should address this topic.
Response rate was calculated from the total number of respondents as compared to the number of unique survey invitations sent. Responses to the survey were analyzed using descriptive statistics. When survey questions offered ranges, (i.e., estimating the number of patients surgically treated), the minimum and maximum values of each of the selected answers were independently summed to report a more comprehensible view of the data. Partially completed surveys were identified individually and accounted for in analysis. Any missing or incomplete data items from the survey were excluded from the results with the denominator adjusted accordingly.
Narrative literature review
A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret and satisfaction. Terms included (regret) and (transgender) and (surgery) or (satisfaction) and (transgender) and (surgery). These terms included their permutations according to the PubMed search methodology. Original research and review studies whose abstracts addressed the following topics were included for full-text review: gender-affirming surgery, sex reassignment, patient satisfaction, detransition, regret. A total of 163 abstracts were reviewed and a total of 21 articles were closely read for the relevant discussion of regret and satisfaction.
This study was approved by the Oregon Health & Science Institutional Review Board #17450 and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.
Of the 154 surgeons who received the survey between December 2017 and February 2018, 46 (30%) surgeons completed the survey. The survey, including its results, can be found in Table S1 . Thirty respondents (65%) were in practice for greater than 10 years, and most (67%) practice in the United States, followed by Europe (22%). The respondents treated between 18,125 and 27,325 TGNC or gender non-conforming (TGNC) patients. Most of the respondents (72%) surgically treated over 100 TGNC patients (see Figure 1 ). Of the 46 respondents, 61% of respondents encountered either at least one patient with regret regarding their surgical transition or a patient who sought a reversal procedure—irrespective of whether their initial surgery was performed by the respondent or another surgeon. Twelve respondents (26%) encountered one patient with regret, and the remaining 12 (26%) encountered two or more patients with regret. One respondent indicated that they encountered between 10 and 20 patients who regretted their surgical gender transition. No respondent encountered more than 20 such patients (see Figure 2 ). This amounted to a total of 62 patients with regret regarding surgical transition, or a 0.2% to 0.3% rate of regret. Of these 62 patients, 13 (21%) involved chest/breast surgery and 45 (73%) involved genital surgery (see Table 1 ).
Distribution of transgender surgery experiences among respondents.
Number of transgender patients encountered who expressed regret.
Totals do not add to 100 due to incomplete responses.
Of the 62 patients who sought surgical reversal procedures, at the time of their initial gender-affirming surgery, 19 patients identified as trans-men, 37 identified as trans women, and 6 identified as non-binary. The reasons for pursuing surgical reversal were provided for 46 patients (74%) and included: change in gender identity or misdiagnosis (26 patients, 42%), rejection or alienation from family or social support (9 patients, 15%), and difficulty in romantic relationships (7 patients, 11%). In some patients, surgical complications or social factors were cited as a reason for regret and request for reversal of genital surgery—no change in the patient’s gender identity was elucidated (see Table 2 , etiologies of regret). Of the 37 trans-women seeking reversal procedures, complaints at the time of secondary surgical consultation included: vaginal stenosis (7 patients), rectovaginal fistulae (2 patients), and chronic genital pain (3 patients). Of the 19 trans-men seeking reversal procedures, complaints at the time of secondary surgical consultation included: urethral fistulae (2 patients) and urethral stricture (1 patient). A total of 36 reversal procedures were reported, with supplemental qualitative descriptions provided for only 23 procedures. The distribution of the 23 reversal procedures is found in Table 1 .
Totals exceed 100 as respondents could select multiple options.
Most respondents (91%) indicated that new mental health evaluations would be required prior to performing surgical reversal procedures. Eighty-eight percent of respondents indicated that WPATH SOC 8 should include a chapter on reversal procedures (see Figure 3 ).
Respondent’s requirements to proceed with surgical reversal.
Overall, the incidence of regret following gender-affirming surgery has been reported to be consistently very low ( 5 - 26 ). Wiepjes et al. ( 27 ) reported an overall incidence of surgical regret in the literature in transgender men as <1% and transgender women as <2%. Landen et al. comment that outcomes following gender-affirming surgery have improved due to preoperative patient assessment, more restrictive inclusion criteria, improved surgical techniques, and attention to postoperative psychosocial guidance ( 28 ). Although retrospective, the Wiepjes et al. study is the largest series to date and included 6,793 patients over 43 years. In this study, only 14 patients were classified as regretful, and only 10 of these patients pursued procedures consistent with intent to detransition. Perhaps most importantly, the Amsterdam team categorized regret into three main subtypes: “ social regret , true regret , and feeling non - binary ”.
Many of the reviewed studies aimed to identify various variables or risk factors that may identify patients that are at risk or that may predict future postoperative regret.
Earlier studies focused on patient characteristics and identified several variables that were associated with regret in their patient populations. These variables include psychological variables ( 11 , 22 , 23 ), such as previous history of depression ( 15 , 26 ), character pathology ( 26 ) or personality disorder ( 5 , 15 ), history of psychotic disorder ( 15 , 28 ), overactive temperament ( 26 ), negative self-image ( 26 ) or other psychopathology ( 15 , 19 , 26 ), as well as various social or familial factors that include history of family trauma ( 19 , 29 ), poor family support ( 5 , 11 , 15 , 28 ), belonging to a non-core group ( 28 ), previous marriage ( 15 , 19 ), and biological parenthood ( 15 , 19 ). Landen et al. identified poor family support as the most important variable predicting future postoperative regret in transgender men and women undergoing gender-affirming surgery in Sweden between 1972–1992 ( 28 ). Defined as subsequent application for reversal surgery, the authors found that 3.8% of their study population regretted their surgery. Other factors previously associated with regret include: sexual orientation ( 5 , 7 , 15 , 19 ), impaired postoperative sexual function [most notably in transgender women; ( 29 )], previous military service ( 29 ), a physically strenuous job ( 29 ), history of criminality ( 5 ), age at time of surgery and transition [>30 year increased risk; ( 5 , 6 , 11 , 15 , 19 , 29 )], asexual or hyposexual status preoperatively ( 15 , 29 ), too much or too little ambivalence regarding prospect of surgery ( 29 ), and/or an absence of gender nonconformity in childhood ( 15 ).
Studies examining transgender women have identified postoperative sexual function to be a significant factor contributing to possible surgical regret ( 15 , 29 ). A literature review by Hadj-Moussa et al. ( 11 ) (2018) identified poor sexual function as a factor that may contribute to postoperative regret in transgender women after vaginoplasty. Lindemalm et al. ( 29 ) (1986) previously reported a rate of 30% regret in their study examining 13 transgender women in Sweden after vaginoplasty. This rate of regret is the highest reported and appears to be an outlier. In their patient population, they found that only one third had a surgically-created vagina capable of sexual intercourse. This was consistent with patient-reported poor postoperative sexual function and highlights the importance of discussing sexual function following vaginoplasty. Similarly, Lawrence et al. ( 15 ) (2003) found that occasional regret was reported in 6% of transgender women after vaginoplasty, with 8 of the 15 regretful patients identifying disappointing physical and functional outcomes after their surgery. These findings are consistent with literature reviews that have found that regret is related to unsatisfactory surgical outcomes and poor postoperative function ( 19 , 30 ).
Transgender men have been found to manifest more favorable psychosocial outcomes following surgery and are less likely to report post-surgical regret ( 26 ). These findings highlight the importance of surgical results, and their influence on surgical regret. Despite this difference between transgender men and women, overall regret continues to remain low.
While the rate of surgical regret is low, many patients can suffer from many forms of “minor regret” after surgery. Although this could skew the outcomes data ( 30 ), this is considered temporary and can be overcome with counseling. As such, this should not be calculated in assessments of true regret ( 30 ). Alternatively, lasting regret is attributed to gender dysphoria and is explicitly expressed through patient postoperative behaviors ( 30 ). Factors that have been found to contribute to “minor regret” after gender-affirming surgery include postsurgical factors such as pain during and after surgery, surgical complications, poor surgical results, loss of partners, loss of job, conflict with family, and disappointments that various expectations linked to surgery were not fulfilled ( 19 ). Previous reviews further underline the importance of following the contemporaneous WPATH Standards of Care. This is especially important regarding patient education pertaining to surgical expectations and outcomes ( 11 , 26 ). Patient education programs are thought to identify those individuals who would most benefit from surgery ( 20 ). Other issues reported to decrease postoperative regret include appropriate preoperative diagnosis ( 19 , 20 , 26 ), consistent administration of hormone therapy ( 15 ), adequate psychotherapy ( 15 ), and the extent to which a patient undergoes a preoperative “real-life test” living in their desired gender role ( 15 , 19 , 20 , 26 ).
As compared to the volume of literature regarding postoperative satisfaction following gender-affirming surgery, the literature on regret is still relatively small. However, the literature (and anecdotal surgeon reports) consistently shows low rates of regret. We juxtaposed these findings to the surgeons’ experience with patients seeking reversal surgery or verbalizing regret. We found a rate of regret between 0.2–0.3%. This is consistent with the most recent data from Wiepjes et al. who reported rates of regret of 0.3% for trans-masculine and 0.6% for trans-feminine patients ( 27 ). The question of prevalence seems relatively well-answered by the current literature.
Perhaps the most striking finding is the heterogeneity of etiologies and risk factors associated with regret. Within this context, establishing consistent definitions for both regret and its underlying etiology is essential. Furthermore, as our understanding of gender identity evolves, our definitions and understanding become more precise. We highlight the Wiepjes et al. classification as an example of how narrower definitions may preclude an understanding of evolving gender theory. This predominantly single-institution study included 6,793 individuals, and the authors classified regret into three subtypes: social regret, true regret, and feeling non-binary. They categorized patients as either trans-female or trans-male. Conversely, in the 2015 US Transgender Survey, 35% of the nearly 28,000 respondents reported a non-binary identification ( 31 ). The classification by Wiepjes et al. is important in that it recognizes that individuals may not regret “transitioning”, but rather regret specific aspects of their medical treatment. More specifically, if these individuals request a reversal procedure, they are not necessarily requesting a “reversal” of their gender identity. However, the Wiepjes et al. study does not elaborate on this topic.
Case example: a trans-masculine, non-binary individual after testosterone therapy and chest masculinization regrets having secondary sex characteristics from hormonal therapy but is highly satisfied following chest masculinization. This should be considered true gender-related regret as the individual desires, at least in part, to return to the phenotype of the sex assigned at birth (e.g., hair removal). However, the etiology regarding this type of regret can be varied. For example, the etiology may include: insufficient exploration of the individual’s gender identity [by the individual and/or mental health professional (misdiagnosis)], lack of knowledge of professionals regarding surgical options for non-binary individuals, insurance carrier mandate to undergo hormonal therapy prior to chest masculinization (healthcare stigma), etc.
Based on the reviewed literature and our consensus expert opinion, we propose the following classification of regret, examples of etiology pertaining to regret ( Table 3 ), and an overview of associated terminology regarding regret ( Table 4 ).
Regret is a general term that describes an emotional state wherein a previous decision now feels incorrect. This can be temporary (fleeting ambivalence) or permanent. Permanent regret can be divided into three forms: true gender-related regret, social regret, and medical regret.
True gender-related regret involves a person having undergone a transition in gender whether by social, medical, or surgical means, indicating a formal change in gender identity, who then desires to return to their assigned sex at birth or a different gender identity. True gender-related regret differs from other types of regret in that it implies a misdiagnosis or misinterpretation of gender incongruence at the time of transition. Based on the case example, true gender-related regret need not be related to all medical treatments, but instead may be focused on specific treatments for which the individual seeks reversal. True gender-related regret constituted 42% of the requests for surgical reversal in our study. Etiology may include: misdiagnosis, insufficient exploration of gender identity, or barriers to access for options to transition to non-binary gender expression.
Social regret refers to one’s desire to return to their sex assigned at birth to alleviate the repercussions of transitioning on their social life. The etiologies can vary widely and include feeling unsafe in public, losing partnership, feeling unable to partake in one’s community, and encountering professional barriers. An additional reason identified in this study included religious conflict, mentioned in 9% of individuals. Social regret was cited in 37.1% of the requests for surgical reversal.
Medical regret includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof. This area is particularly important for the medical community as it is preventable and may increase as access to care expands. Medical regret can be further subdivided into regret secondary to medical complications, long-term functional outcomes (i.e., sexual), and preoperative decision-making.
Medical regret due to inadequate preoperative decision-making is directly related to a medical intervention, but it is not due to a change in gender identity, medical complication, functional outcome, or social stigma. Examples include choosing a simple-release metoidioplasty rather than a phalloplasty or regretting gonadal sterilization later in life ( 32 ). In these situations, individuals may not have appreciated the long-term implications at the time they underwent the procedure, may have received incomplete or inaccurate counseling, may have had a change in life goals, or may have not had access to technologies that are currently available. This form of regret may be mitigated by employing a multidisciplinary approach which includes discussions beyond surgical risks (i.e., fertility preservation, sexuality, etc.) ( 33 , 34 ). Medical regret was cited in 8% of requests for reversal, however 24% of patients were separately noted to have experienced post-operative complications.
Gender fluidity is an inclusive term describing gender along a spectrum rather than a binary construct. When applied to identity, gender fluidity, sometimes called “genderqueer” ( 35 , 36 ) describes an individual who remains flexible regarding their identity and may identify differently at different times in their lives. Surgeons should work collaboratively with their mental health colleagues to help the patient understand the impact of surgery and how surgery may influence/affect future life goals. Non-identified gender fluidity can be one etiology for true gender-related regret.
Continued transition medically recognizes the concept of gender fluidity and the gender spectrum. This patient seeks additional medical treatment following their initial gender-affirming procedure(s) and may express an evolving gender identity or request further surgical consolidation of their identity. The patient need not express regret over their initial transition. An example is a patient assigned male-at-birth who takes feminizing hormones and undergoes breast augmentation. Subsequently, the patient returns to the surgeon indicating they identify as non-binary and requests implant removal. With decreased stigmatization of non-binary gender identity and ability to access non-binary affirming surgical options, this type of regret may be less common in the future.
Detransition refers to a change in gender role and/or the cessation of medical transition (e.g., hormonal treatment). This term has been used controversially and disparagingly with regards to surgical transition and fails to honor the spectrum of reasons why patients may undergo reversal surgery. However, some patients utilize this term to self-identify and to describe their experiences. This term should not be used to describe the process of surgical reversal.
Retransition is a phenomenon where a patient, following surgical reversal procedures, later feels that this reversal was wrong and seeks to re-affirm their previously expressed gender identity. A reason for retransition may include a change in societal structure that has provided a safer environment for transition. The need to distinguish continued transition from retransition results from a clash between increasing societal perception of a gender spectrum and the Western culture’s binary gender construct ( 35 ).
Fleeting ambivalence (considered short-term regret) over one’s transition is common, especially if the patient experiences initial surgical complications or loss of their support communities. The normal grief experienced as a result of trauma should not be pathologized, and the patient should be encouraged to trust in their long-standing gender identification. Some patients may desire a change in gender identify as a result of feeling unsafe due to severe social stigma. Knowing this, healthcare teams should counsel patients regarding the implications of transitioning within a given societal structure prior to surgery. This may include discussions regarding the effect of transitioning on relationships, careers, personal safety in public, sexuality, etc. These discussions are often facilitated by the patient’s mental health professional and/or primary care provider.
We recognize that regret and surgical reversal are complex, multifaceted phenomena without an easy treatment path. While both regret and requests for surgical reversal are rare, the need for guideline development is critical in providing high-quality care for this patient population, regardless of prevalence.
A concern expressed by both providers and patients is that discussions regarding regret and surgical reversal may be used to restrict access to affirming care. The authors believe that research including feelings of grief and regret will not only help individuals who experience severe forms of regret but will also help to refine surgical indications and procedures to minimize this already rare occurrence. Finally, and perhaps most importantly, failure to study regret and surgical reversal procedures will allow these topics to be left up to interpretation and may not reflect the actual experience of patients.
The literature review was not performed systematically and as such is subject to selection bias. Our survey involved a survey of gender surgeons but did not include other medical or mental health professionals who may evaluate patients requesting surgical reversal. In addition, the study findings are limited by its design. Because survey studies are prone to recall bias, response bias, and selection bias, they are not well-suited for calculating the prevalence of a particular condition. For example, 89% of the respondents practice in the United States and Europe. This leaves significant areas of the world underrepresented and so does not represent the experiences or desires of all international surgeons. Furthermore, the survey was distributed in English only, as it was circulated to surgeons who attended conferences in the United States. Most notably, patients may have sought consultation from multiple surgeons resulting in an overestimation of the prevalence of regret. Conversely, patients seeking surgical reversal may not have had access to additional surgical care, causing an underestimate in the prevalence of regret. While our study findings are strengthened by external validation from other studies, the true prevalence of regret remains an estimate.
Regret after gender-affirming surgery was found to be rare, both in the literature as well as in our survey of surgeons’ experiences with this topic. Regret can be classified as true gender-related regret, social regret and medical regret from complications, function, pre-intervention decision making. Guidelines in transgender health should include both preventive strategies as well as treatment guidelines if regret occurs. Future studies and scientific discourse are encouraged on this important topic.
The authors acknowledge the many surgeons who were surveyed in this work, and the community members who thusly contributed to the survey results.
This research was orally presented by Dr. Sasha Narayan at the Philadelphia Trans Wellness Conference (PTWC) August 2018 in Philadelphia, PA and at the World Professional Association for Transgender Health (WPATH) International Conference, November 2018 in Buenos Aires, Argentina. This research was orally presented by Dr. Sara Danker at Plastic Surgery, The Meeting (PSTM), October 2018 in Chicago, IL.
Funding : None.
Ethical Statement : The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Oregon Health & Science Institutional Review Board #17450. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/ .
Provenance and Peer Review : This article was commissioned by the Guest Editors (Drs. Oscar J. Manrique, John A Persing, and Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine . The article has undergone external peer review.
Reporting Checklist : The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-6204
Data Sharing Statement : Available at http://dx.doi.org/10.21037/atm-20-6204
Conflicts of Interest : All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6204 ). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. RBL reports that he serves on the standards of care committee of WPATH. No financial reward. Dr. AR reports that he serves as board member for World Professional Association for Transgender Health. This is an uncompensated position. Dr. LS reports other from Elsevier Publishing, other from Springer Publishing, outside the submitted work; and he serves on the board of WPATH (world professional association for transgender health), this is an unpaid position. Dr. JUB reports that he serves on the standards of care committee of the World professional association of transgender health. No financial reward associated with this. The authors have no other conflicts of interest to declare.
Gender reassignment surgery: an overview
- 1 Gender Surgery Unit, Charing Cross Hospital, Imperial College NHS Trust, 179-183 Fulham Palace Road, London W6 8QZ, UK.
- PMID: 21487386
- DOI: 10.1038/nrurol.2011.46
Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.
- Plastic Surgery Procedures / methods*
- Plastic Surgery Procedures / psychology
- Postoperative Complications / prevention & control
- Postoperative Complications / psychology
- Sex Reassignment Surgery / methods*
- Sex Reassignment Surgery / psychology
- Transsexualism / diagnosis
- Transsexualism / psychology
- Transsexualism / surgery*
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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.
- 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.
Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.
Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.
Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).
Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.
Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.
Patients and Methods
Subjects and study setup.
This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.
At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.
Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.
The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.
Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.
At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).
Figure 1 . The initial circumferential subcoronal incision.
Figure 2 . The de-gloved penis being passed through the scrotal opening.
Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.
Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.
Figure 5 . The inverted penile skin flap.
Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.
Figure 7 . The final appearance after the completion of the procedures.
Postoperative Care and Follow-Up
The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.
Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.
The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.
Figure 8 . Appearance after 1 month of the procedure.
The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.
During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .
Table 1 . Patient demographics.
Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.
The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).
Table 2 . Complications after penile inversion vaginoplasty.
A total of 36 patients (16.8 percent) underwent some form of reoperation.
One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.
Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.
The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).
There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.
The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.
In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).
Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.
One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).
Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).
Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).
Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.
The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.
Data Availability Statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.
GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.
This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome
Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430
Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.
Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Gabriel Veber Moisés da Silva, firstname.lastname@example.org
This article is part of the Research Topic
Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion
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A decision to undertake gender reassignment is made when an individual feels that his or her gender at birth does not match their gender identity. This is called ‘gender dysphoria’ and is a recognised medical condition.
Gender reassignment refers to individuals, whether staff, who either:
- Have undergone, intend to undergo or are currently undergoing gender reassignment (medical and surgical treatment to alter the body).
- Do not intend to undergo medical treatment but wish to live permanently in a different gender from their gender at birth.
‘Transition’ refers to the process and/or the period of time during which gender reassignment occurs (with or without medical intervention).
Not all people who undertake gender reassignment decide to undergo medical or surgical treatment to alter the body. However, some do and this process may take several years. Additionally, there is a process by which a person can obtain a Gender Recognition Certificate , which changes their legal gender.
People who have undertaken gender reassignment are sometimes referred to as Transgender or Trans (see glossary ).
Transgender and sexual orientation
It should be noted that sexual orientation and transgender are not inter-related. It is incorrect to assume that someone who undertakes gender reassignment is lesbian or gay or that his or her sexual orientation will change after gender reassignment. However, historically the campaigns advocating equality for both transgender and lesbian, gay and bisexual communities have often been associated with each other. As a result, the University's staff and student support networks have established diversity networks that include both Sexual Orientation and Transgender groups.
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In 1952 a 27-year-old, former WWII-era GI from New York named George Jorgensen traveled to Denmark, and returned to the U.S. as Christine Jorgensen. Jorgensen, who had described herself as a woman trapped in a man's body, was one of the first to transition from the male to female gender through a process involving hormone therapy and surgical procedures [source: Hadjimatheou ]. In time, she became a trailblazer in seeking those gender reassignment surgeries as these procedures, now known as gender realignment (reconstruction, affirmation or confirmation) surgeries, wouldn't begin in the U.S. until 1966 [source: Wexler ].
Gender identity struggles usually begin in early childhood but descriptions of feeling like a man trapped inside a woman's body, or vice versa, have been identified in and reported by people of all ages. A person living with this an internal conflict may develop anxiety and depression, and go on to be diagnosed with gender dysphoria, formally known as gender identity disorder (GID). Gender dysphoria is a mental health condition that can arise when a person lives with ongoing feelings of being physically incongruous with his or her birth sex — and medical intervention may be beneficial. Identifying as transgender, itself, is considered by scientists to be, at least in part, biological and not a mental illness [source: HRF ].
Being transgender also isn't about anatomy or sexual orientation; it's about internally identifying with a gender status — which could be masculine, feminine, agender or gender fluid — that is different than the one culturally assigned to you based upon your physical characteristics. While some people may never publicly acknowledge their transgender status, others may decide to live as their desired gender — and that could mean changing how they express their gender through transitioning.
Transitioning is often two-fold: a social transition, such as new clothing, a new name and new pronouns; and a medical transition, with treatments such as hormone therapy and surgical procedures. Depending on the needs and wants of each individual, transitioning may include both social and medical transitions; just one of the two; or for those who eschew gender completely, neither.
Diagnosing Gender Dysphoria
Gender affirmation surgery.
Gender transition is a process unique to each individual, and for those who do choose to affirm their gender with a medical transition, the path often consists of counseling and a diagnosis of gender dysphoria, hormone therapy and real-life experience before genital-changing surgeries are performed. Not all transgender people need — or want — these therapies; and, not all transgender people undergo surgery. Those who do choose to medically transition may select a number of procedures, or focus on just "top," "bottom" or cosmetic surgeries. The collection of procedures are also commonly called gender reassignment or — and the process begins long before the procedures do.
It begins with psychotherapy; in addition to providing counsel, mental health professionals assess a person's readiness for hormone therapy and surgery. To become a candidate for gender reassignment surgery, a person must first be diagnosed with gender dysphoria, as defined by the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a common language and standards protocol manual for the classification of mental disorders. Gender dysphoria was previously known as gender identity disorder (GID) and broken into a handful of classifications (such as childhood and adulthood) in the DSM-4. The revision was made not only to help ensure access to care while attempting to reduce the stigma associated with gender identity struggles, but it also removed the concomitance between transgender feelings and mental illness.
Having persistent feelings — for at least six months — that a person's birth sex doesn't align with his or her gender identity isn't considered a behavioral health issue. To be diagnosed with gender dysphoria, adults and adolescents must also exhibit at least two other conditions, including [source: APA ]:
- An outward expression of gender that differs from what society expects
- The desire to be a different gender
- The wish to be treated as a different gender
- The desire to get rid of the primary and secondary sex characteristics of the "wrong" gender
- The wish to have the sexual characteristics of a different gender
- The belief their gender reactions are of a different gender
The desire for gender change cannot be a symptom of another disorder or a chromosomal abnormality. Additionally, these gender identity issues must cause distress, personally, socially, professionally or in any other manner [source: APA ].
After counseling, evaluation and diagnosis, patients don't immediately schedule a vaginectomy (removal of the vagina), or penectomy (removal of the penis). Those who choose gender affirmation surgery will need letters of recommendation from counselors, psychiatrists, psychologists, sexologists and/or therapists prior to major gender reconstructive surgery.
Doctors normally recommend hormone therapy to alter secondary sex characteristics to the desired gender before surgery. Other than surgeries to reconstruct internal and external genitalia (and not counting anything considered a cosmetic procedure), most physical changes are managed with hormone therapy prescribed by an endocrinologist to suppress certain characteristics (such as distribution of body hair) or enhance certain others (such as breast growth). Hormone therapy may continue for a few years (it takes at least two years to achieve maximum results), and may be concurrent with what's known as the Real-Life Experience (RLE), a year dedicated to living openly as one's desired gender, and intended to help adjust — socially, physically and emotionally — to making these significant changes in gender expression [source: WPATH ].
It's difficult to know for certain what the actual numbers are, but the Williams Institute estimates that that about 0.3 percent of the general U.S. population identifies as transgender, although not all of those 1.5 million people will desire or undergo gender affirmation surgery [sources: Gates , Steinmetz ]. Each year between 100 and 500 gender reconstruction surgical procedures are done in the U.S. to treat gender dysphoria. The United States is not a major player in gender dysphoria treatment; estimates range that up to 2,500 people worldwide affirm their gender through surgery every year — and Thailand has long been considered the premiere destination for gender surgeries [sources: Toro , Encyclopedia of Surgery ].
Gender affirmation surgery is performed under the guidelines of World Professional Association for Transgender Health's (WPATH) globally accepted Standards of Care for Gender Identity Disorders (SOC). The types of surgeries to be conducted are decided by the patient's desire and comfort level, as well as finances. Not every patient will want or need the same surgeries, and the process is tailored for each individual. Certain procedures are considered medically necessary to treat gender dysphoria, while other common gender confirmation surgeries such as rhinoplasty and brow lifts are considered cosmetic; for some this new outward appearance may hold more significance than the reconstruction of internal and external genitalia.
Surgeries for trans men (or those assigned female at birth (AFAB)) include:
- Bilateral mastectomy;
- Complete hysterectomy
- Reconstruction of the genitalia with a metoidioplasty (a procedure that allows a surgeon to construct a phallus from the clitoris)
- Ring metoidioplasty (to lengthen the urethra)
- Scrotoplasty (the construction of a scrotum)
- Vaginectomy (to close of the vaginal canal)
- Phalloplasty (the construction of the penis)
A penile implant (a prosthetic otherwise used to treat erectile dysfunction) and testicular implants may also be added to the reconstructed penis and testes. Although the mean length of a reconstructed penis is roughly 2 inches (5 centimeters), 80 percent of trans men in one study reported they were able to engage in sexual intercourse, and most experienced orgasms [source: Harrison ].
Trans women, or those assigned male at birth (AMAB), a group larger in number than trans men, may begin their physical transformation with breast augmentation (implants), as well as with cosmetic surgeries to feminize the face and body, such as facial feminization surgery (FFS) , and gluteal, hip and thigh implants before undergoing genital reconstruction. Surgeries to create female genitalia include:
- Clitoroplasty (the construction of a clitoris)
- Labiaplasty (the creation of a labia from scrotum skin)
- Orchiectomy (testicle removal)
- Prostatectomy (the removal of prostate)
- Urethroplasty (the reconstruction of the urethra)
- Vaginoplasty (the creation of the vaginal canal, made from penile tissue or a colon graft)
- Penectomy (removal of the penis) is usually done concurrently with vaginoplasty, and a clitoral hood is typically constructed from the glans penis.
In the U.S. surgical costs in 2015 may run anywhere from about $25,000 for male-to-female transitions and upwards of $100,000 or more for female-to-male transitions, although typical costs fall between $7,000 and $50,000 [sources: Leitsinger , AP ]. Transgender Brits pay about 10,000 pounds ($15,000) [source: Telegraph ]. And for an extra $8,000, patients transitioning from female to male in Thailand can, for example, upgrade from a 1 inch (2.5 centimeter) penis to one with a few more inches [source: Ehrlich ].
Transgender people who have undergone gender affirmation surgeries are, in almost all cases, happy they did so. In the U.K., for instance, only 2 percent of people who've undergone gender reconstructive surgeries report regretting their physical transformation, compared to 65 percent of cisgender (non-transgender) people who report regretting their plastic surgery choices [source: Tannehill ]. And in the U.S. less than 1 percent of trans women regret their genital reconstruction, a percentage that's been decreasing alongside the risk of developing long-term complications [source: Tannehill ]. More than 80 percent of patients report long-term satisfaction despite (treatable) complications such as vaginal hair growth (a 29 percent prevalence among trans females) and urinary problems (almost the same, at 27 percent) [source: Goddard ]. The rate of regret for trans men is difficult to estimate, as they are smaller in number than trans women [sources: Jarolím , Tannehill ].
Sure, there's the case of Charles Kane, who famously transitioned from a man to a woman in 1997, and then back again. After living as Samantha Kane for seven years, Charles decided he would never pass as a "real woman," neither to himself or to the public, and felt hormone therapy altered his brain into making the original decision [source: Scutti ]. But, Kane is a rarity.
Lots More Information
Author's note: how gender reassignment works.
The terminology surrounding gender identity, expression and affirmation has changed a lot since I first wrote about gender dysphoria, then called gender identity disorder, and the ins and outs of, what was then called gender reassignment surgery. The first thing I noticed 8 years later is that there is a lot more labeling. For instance: A biologically born man who identifies as a woman may be known as an 'affirmed' or 'confirmed' woman, 'transgender' woman, or you may also hear the term 'trans woman' — all in reference to the same woman. For some, 'transsexual' continues to be used. And then there's also the acronyms, such as MTF (or M2F), which stands for male-to-female, and AMAB (or DMAB), indicating 'assigned male at birth' (and 'designated male at birth'). I'm sure I'm overlooking some, too. And it's a similar list for someone assigned female at birth who identifies as a man (AFAB). What seems to be left out, though is the most obvious: male and female, just as those who are cisgender (a term used for non-trans people). (Unless, of course, we're talking about a person whose identity lies somewhere along a spectrum of gender, who may prefer to describe themselves as neither male nor female, but gender fluid.)
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More Great Links
- National Center for Transgender Equality
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- World Professional Organization for Tansgender Health (WPATH)
- Aetna. "Clinical Policy Bulletin: Gender Reassignment Surgery." Sept. 19, 2014. (April 12, 2015) http://www.aetna.com/cpb/medical/data/600_699/0615.html
- American Medical Student Association (AMSA). "Transgender Health Resources." (April 12, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
- American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." Excerpt from: The Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. Feb. 18, 2011. (April 12, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
- Bilefsky, Dan. "Serbia Becomes a Hub for Sex-Change Surgery." The New York Times. July 23, 2012. (April 12, 2015) http://www.nytimes.com/2012/07/24/world/europe/serbia-becomes-a-hub-for-sex-change-surgery.html
- Dewey, Caitlin. "Confused by Facebook's new gender options? Here's what they mean." The Washington Post. Feb. 14, 2014. (April 12, 2015) http://www.washingtonpost.com/blogs/style-blog/wp/2014/02/14/confused-by-facebooks-new-gender-options-heres-what-they-mean/
- Ehrlich, Richard s. "Everything you always wanted to know about sex... changes." CNN. Feb. 24, 2010. (April 12, 2015) http://travel.cnn.com/bangkok/play/everything-youve-ever-wanted-know-about-sex-changes-379486
- Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
- Goddard, Jonathan C. "Feminizing genitoplasty in adult transsexuals: early and long-term surgical results." BJU International. Vol. 100, no. 3. Pages 607-613. July 2007. (April 12, 2015) http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2007.07017.x/pdf
- Goldberg, Joseph. "When You Don't Feel At Home With Your Gender." WebMD. Sept. 24, 2014. (April 12, 2015) http://www.webmd.com/mental-health/gender-dysphoria
- Hadjimatheou, Chloe. "Christine Jorgensen: 60 years of sex change ops." BBC News. Nov. 30, 2012. (April 12, 2015) http://www.bbc.com/news/magazine-20544095
- Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape. May 20, 2013. (April 12, 2015) http://www.medscape.com/viewarticle/804432
- HealthResearchFunding.og (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 12, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
- International Foundation for Gender Education (IFGE). "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 12, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
- Jarolím, L. "Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks." The Journal of Sexual Medicine. Vol. 6, no. 6. Pages 1635-1644. June 2009. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pubmed/19473463
- Kourkounis, Erin. "Tampa transgender teen living life of transition." The Tampa Tribune. (April 12, 2015) http://tbo.com/news/education/tampa-transgender-teen-living-life-of-transition-20150412/
- Lallanilla, Marc. "Gender Reassignment Surgery: How Does It Work?" Huffington Post - HuffPost Healthy Living. Oct. 23, 2015. (April 12, 2015) http://www.huffingtonpost.com/2013/08/23/gender-reassignment-surgery-manning-bradley-chelsea_n_3804247.html
- Leitsinger, Miranda. "Sex Reassignment Surgery at 74: Medicare Win Opens Door for Transgender Seniors." NBC News. Jan. 3, 2015. (April 12, 2015) http://www.nbcnews.com/news/us-news/sex-reassignment-surgery-74-medicare-win-opens-door-transgender-seniors-n276986
- McGinn, Christine. "Services." Gender Wellness Center Papillon. 2010. (April 12, 2015) http://www.drchristinemcginn.com/services/
- Monstrey, Stan J. "Sex Reassignment Surgery in the Female-to-Male Transsexual." Seminars in Plastic Surgery. Vol. 25, no. 3. Pages 229-244. August 2011. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/
- Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. (April 12, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
- Scutti, Susan. "Becoming Transsexual: Getting The Facts On Sex Reassignment Surgery." Medical Daily. Nov. 6, 2014. (April 12, 2015) http://www.medicaldaily.com/becoming-transsexual-getting-facts-sex-reassignment-surgery-309584
- Selvaggi, G. "Genital sensitivity after sex reassignment surgery in transsexual patients." Annals of Plastic Surgery. Vol. 58, no. 4. Pages 427-433. April 2007. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pubmed/17413887
- Tannehill, Brynn."Myths About Transition Regrets." Huffington Post - HuffPost Gay Voices. Jan. 18, 2015. (April 12, 2015) http://www.huffingtonpost.com/brynn-tannehill/myths-about-transition-regrets_b_6160626.html
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- The Telegraph. "Number of NHS sex change operations triples." April 21, 2010. (April 12, 2015) http://www.telegraph.co.uk/news/health/news/7613567/Number-of-NHS-sex-change-operations-triples.html
- Toro, Ross. "How Gender Reassignment Surgery Works (Infographic)." LiveScience. Aug. 26, 2013. (April 12, 2015) http://www.livescience.com/39170-how-gender-reassignment-surgery-works-infographic.html
- University of California San Francisco - Center of Excellence for Transgender Health. "Transgender Health Learning Center: Surgical Options." (April 12, 2015) http://transhealth.ucsf.edu/trans?page=protocol-surgery
- University of Miami - Miller School of Medicine. "Plastic Aesthetic and Reconstructive Surgery: Transgender Reassignment." 2015. (April 12, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
- University of Michigan Health System. "Transgender Services: Gender Affirming Surgery." (April 12, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
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Definition of gender reassignment
Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than making changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.
1969, in the meaning defined at sense 2
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Cite this Entry
“Gender reassignment.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment. Accessed 19 Nov. 2023.
Medical definition of gender reassignment.
Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than makes changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.
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Preparation and Procedures Involved in Gender Affirmation Surgeries
If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.
Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.
A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.
The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.
Transitioning may involve:
- Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
- Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs
Transgender individuals do not need to undergo medical intervention to have valid identities.
Reasons for Undergoing Surgery
Many transgender people experience a marked incongruence between their gender and their assigned sex at birth. The American Psychiatric Association (APA) has identified this as gender dysphoria.
Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.
For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.
Steps Required Before Surgery
In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.
Steps may include:
- Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.
- Clear and consistent documentation of gender dysphoria
- A "real life" test : The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).
Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.
Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.
Hormone Therapy & Transitioning
Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.
The purpose of hormone therapy is to change the physical appearance to reflect gender identity.
Effects of Testosterone
When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.
Bodily changes can include:
- Beard and mustache growth
- Deepening of the voice
- Enlargement of the clitoris
- Increased growth of body hair
- Increased muscle mass and strength
- Increase in the number of red blood cells
- Redistribution of fat from the breasts, hips, and thighs to the abdominal area
- Development of acne, similar to male puberty
- Baldness or localized hair loss, especially at the temples and crown of the head
- Atrophy of the uterus and ovaries, resulting in an inability to have children
Behavioral changes include:
- Increased sex drive
Effects of Estrogen
When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.
Changes to the body can include:
- Breast development
- Loss of erection
- Shrinkage of testicles
- Decreased acne
- Decreased facial and body hair
- Decreased muscle mass and strength
- Softer and smoother skin
- Slowing of balding
- Redistribution of fat from abdomen to the hips, thighs, and buttocks
- Decreased sex drive
- Mood swings
When Are the Hormonal Therapy Effects Noticed?
The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition. This is especially true for breast development.
Timeline of Surgical Process
Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.
Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.
Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.
Top surgery includes:
- Breast augmentation
- Facial feminization
- Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
- Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.
- Jaw surgery: The jaw bone may be shaved down.
- Chin reduction: Chin reduction may be performed to soften the chin's angles.
- Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.
- Lips: A lip lift may be done.
- Alteration to hairline
- Male pattern hair removal
- Reduction of Adam’s apple
- Voice change surgery
Bottom surgery includes:
- Removal of the penis (penectomy) and scrotum (orchiectomy)
- Creation of a vagina and labia
Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.
Surgery for this group involves top surgery and bottom surgery as well.
Top surgery includes :
- Subcutaneous mastectomy/breast reduction surgery.
- Removal of the uterus and ovaries
- Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty
Complications and Side Effects
Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people. There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).
Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.
With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.
Cost of Gender Confirmation Surgery
Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.
Quality of Life After Surgery
Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.
Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.
A Word From Verywell
Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.
After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.
After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.
Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus. Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.
For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.
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- gender reassignment
male-to-female or female-to-male transformation involving surgery and hormone treatment
Words Nearby gender reassignment
- gender reveal
- gender role
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How to use gender reassignment in a sentence
Last May, Israel lowered the minimum age for gender reassignment surgery from 21 to 18.
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If Your Time is short
An October episode of Tucker Carlson’s show on X, formerly Twitter, focused on gender-affirming care for transgender people. In contrast to his guest’s claim, there are many long-term, peer-reviewed studies that examine the efficacy and effects of hormonal treatment in trans adults.
Experts also say that Carlson’s comparison of gender-affirming surgeries and female genital mutilation is wrong. One is done with consent to preserve sexual function, the other is not.
Carlson’s guest also made claims about the size of the trans health care market in billions of dollars. But experts say without knowing the methodology behind those calculations, it is hard to determine the estimate’s accuracy.
Since his firing from Fox News, former primetime host Tucker Carlson has taken his show on the digital road — to X, where he has interviewed public figures such as former President Donald Trump and independent presidential candidate Robert F. Kennedy Jr .
On Oct. 4, Carlson released an episode titled "Trans, Inc" that focused on gender-affirming health care provided to transgender people. "Genital mutilation is not just a fad. It’s a full-blown industry," read the caption on Carlson’s X post sharing the episode. The 48-minute video criticized aspects of transgender health care, such as hormones, surgery and social affirmation. It describes "transgenderism" as "unnatural" and "demented," comparing it with "human sacrifice." Carlson could not be reached for comment.
In the video, Carlson interviewed Chris Mortiz, whom Carlson introduced as a "policy guy" who has "taken a close forensic look at where the money is coming from." From his limited online presence, we found that Moritz has worked as a lawyer, investment banker and consultant. Mortiz did not respond to our requests for comment. The video included some claims we have fact-checked before . But here are three new assertions involving hormone treatments, gender-affirming surgeries and the trans health care market.
Moritz’s description of a total lack of research is inaccurate. The Endocrine Society’s Clinical Practice Guidelines state, "Prior to 1975, few peer-reviewed articles were published concerning endocrine treatment of transgender persons. Since then, more than two thousand articles about various aspects of transgender care have appeared." PolitiFact found several published and peer-reviewed studies examining the long-term effects and efficacy of cross-sex hormone treatment on bone health , cardiovascular risk, mortality , psychosocial functioning and more. There is enough research that we found systematic reviews — analyses of large numbers of individual research studies — on specific aspects of treatment like bone health.
Although adolescent treatment for gender dysphoria started only in the late 1990s , transgender adults have received hormonal treatment and sex reassignment surgery since the early 1970s .
Additionally, people who aren’t transgender, including men with low testosterone and women in menopause , sometimes rely on hormone therapy.
"Hormone therapy for transgender males and females confers many of the same risks associated with sex hormone replacement therapy in nontransgender persons," the Endocrine Society’s Clinical Practice Guidelines say.
The guideline outlines safe dosages and provides guidance for how physicians should monitor for potential adverse effects.
Female genital mutilation is a nonconsensual procedure that can include the partial or total removal of the clitoris, labia minora or the narrowing of the vaginal opening. The World Health Organization said it is mostly forced on girls younger than 15. More than 200 million women have been affected in 30 countries in Africa, Asia and the Middle East.
The procedure aims to reduce or eliminate sexual function and pleasure. It is widely considered a human rights violation. Dr. Marci Bowers, a gynecological surgeon who does gender-affirming genital surgeries and restorative surgeries for female genital mutilation survivors, told PolitiFact that gender-affirming surgeries do not amount to genital mutilation — the two are entirely different. "Transgender surgery is done with full consent of the individual," Bowers said. Female genital mutilation is usually forced on girls younger than 15 in nonmedical and unsterile conditions. Gender-affirming surgeries, however, are performed in hospitals by trained professionals, and are rarely performed on people younger than 18, said Bowers, president of the World Professional Association for Transgender Health. When gender-affirming surgery is performed on minors, it is "only under the most severe conditions of gender dysphoria," she said.
Bowers also noted the difference in how the two procedures affect women’s sexual functionality — such as the ability to have sensation or orgasm. Gender-affirming surgeries "are generally quite elegant surgeries that leave the individual fully functional versus (female genital mutilation), which robs a woman of functionality," she said.
Mariya Taher, co-founder of Sahiyo , an organization working in Asia to end female genital mutilation, agreed with Bowers. Taher told PolitiFact her organization "strongly" believes that gender-affirming health care does not equate to genital mutilation.
"We are saddened to see the two issues are being conflated" and that female genital mutilation "is being used as a guise to target and harm trans youth and gender-diverse individuals" Taher said. Additionally, representatives from the End FGM network in both the U.S. and Europe told PolitiFact that female genital mutilation and gender-affirming surgeries are not the same.
We are unsure how Moritz arrived at those numbers; he offered no evidence backing them up and did not answer our inquiries. We found a few publicly available market research reports, which are often commissioned by investors deciding whether to invest in a given industry. But it is difficult to assess the reliability of these reports without knowing the methodology behind them, and estimates can vary widely, said experts. Carlson made a broader assertion that profits are driving transgender health care: "Transgenderism, it didn't happen by accident," he said. "Some people are profiting from it."
None of the 2022 reports we found for the U.S. market added up to $4.18 billion, but some got close. Grand View Research, for example, values the U.S. sex reassignment hormone therapy market at $ 1.6 billion and the U.S. sex reassignment surgical market at $ 2.1 billion in 2022.
These values can be calculated using a combination of insurance data, federal and state data, and information directly from medical providers, explained Stephen Parente, professor of finance at the University of Minnesota Carlson School of Management. But for procedures not reimbursed by insurance, getting accurate estimates might prove more challenging. Coverage of health care services for transgender people can differ by state and health plan, according to HealthCare.gov .
"Most types of health care, including gender affirming care, involve multiple types of providers of goods and services — e.g., drugs, visits, procedures, hospital stays, etc." said Melinda Buntin, health economist and professor at Johns Hopkins Bloomberg School of Public Health. "For this reason, it is hard to assess how much is spent on specific categories of care in sum." The market size can vary depending on what is included in a given estimate, said Supriya Munshaw, associate professor at Johns Hopkins Carey School of Business. Is it just surgery or is the hospital stay included? What about complications? How do they determine what mastectomies are gender-affirming and which are done for breast cancer?
"How are you actually calculating the number?" said Munshaw. "It might differ in different research reports."
The U.S. health care market is large to begin with, totaling $4.3 trillion in 2021, according to federal data on national health expenditures . A market of billions is a "sizable market" from an investment perspective, Munshaw said, but "it doesn't mean that if something is profitable that the healthcare industry is pushing it." PolitiFact Researcher Caryn Baird contributed to this report. CORRECTION, Nov. 15, 2023: Melinda Buntin is health economist and professor at Johns Hopkins Bloomberg School of Public Health. Her name was misspelled in an earlier version of this story.
Interview with Stephen Parente, Professor of Finance at the University of Minnesota Carlson School of Management, Nov. 14, 2023
Email interview with Melinda Buntin, health economist and professor at Johns Hopkins Bloomberg School of Public Health, Nov. 7, 2023
Interview with Supriya Munshaw, associate professor at Johns Hopkins Carey School of Business, Nov. 13, 2023
Email Interview with Mariya Taher, Co-founder and U.S. Executive Director of Sahiyo, Nov. 8, 2023
Email Interview with Caitlin LeMay, Director of End FGM US Network, Nov. 13, 2023
Email Interview with Myriam Mhamedi, Senior Communications and Campaign Officer at End FGM European Network, Nov, 10, 2023
Interview with Marci Bowers, Gynecological surgeon and President of the World Professional Association for Transgender Health, Oct. 12, 2023
Email interview with Jenni Gingery, Director of Communications and Media Relations at the Endocrine Society, Oct. 12, 2023
X post ," Aug. 14, 2023
X post ," Aug. 23, 2023
X post ," Oct. 4, 2023
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PolitiFact, " No, California no separará a padres de hijos por debates de identidad de género ," Sept. 25, 2023
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2 Transgender Boys Sue After University of Missouri Halts Gender-Affirming Care to Minors
Two transgender boys are suing the University of Missouri over its decision to stop providing gender-affirming care to minors over concerns that a new state law could create legal issues for its doctors
FILE - Glenda Starke wears a transgender flag at a counterprotest during a rally in favor of a ban on gender-affirming health care legislation, March 20, 2023, at the Missouri Statehouse in Jefferson City, Mo. In a lawsuit filed in federal court, Thursday, Nov. 16, 2023, two transgender boys are suing the University of Missouri over its decision to stop providing gender-affirming care to minors over concerns that a new state law could create legal issues for its doctors. (AP Photo/Charlie Riedel, File) Charlie Riedel
Two transgender boys are suing the University of Missouri over its decision to stop providing gender-affirming care to minors over concerns that a new state law could create legal issues for its doctors.
The lawsuit, filed Thursday in federal court, alleges that the university is discriminating against the teens based on their diagnoses of gender dysphoria.
The new Missouri law, which took effect Aug. 28 , outlawed puberty blockers, hormones and gender-affirming surgery for minors. But there are exceptions for youth who were already taking those medications before the law kicked in, allowing them to continue receiving that health care.
The suit said that the teens, who are identified only by their initials, should be covered under that “grandfather clause” and allowed to continue receiving treatment.
University of Missouri spokesperson Christian Basi said Friday that the four-campus system is reviewing the lawsuit and is not in a position to discuss it.
Asked about it Thursday after a Board of Curators meeting, University President Mun Choi said the school's position was that it “would follow the law of the land.”
The University of Missouri Health Care stopped treatments for minors in August. Washington University Transgender Center at St. Louis Children’s Hospital followed suit in September, saying the law “creates unsustainable liability for health-care professionals."
The issue the institutions cited is that health care providers who violate the transgender health care law face having their medical licenses revoked. Beyond that, any provider who prescribes puberty blockers and hormones as a form of gender-affirming care for minors could face lawsuits from those patients for as long as 15 years after they turn 21.
“Providers could be held liable for damages even if they did not do anything wrong or unreasonable,” Basi said at the time.
But since the announcement, neither teen has been able to find other health care providers in Missouri willing to refill their prescriptions. By February, K.J. will run out of puberty-delaying medication and J.C. will run out of testosterone, the lawsuit said.
Going without, the lawsuit adds, would be “deeply traumatic” and cause “severe emotional and physical distress.”
J. Andrew Hirth, an attorney for the plaintiffs, didn't immediately respond to an email or phone message from The Associated Press seeking comment.
But he wrote that the university's policy change discriminates based on gender and "has nothing to do with its doctors’ medical judgment or the best interests of its transgender patients.”
Copyright 2023 The Associated Press . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
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Tags: Associated Press , politics , health , gender , crime , lawsuits , Missouri , education
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Gender Reassignment Surgery Statistics: Market Report & Data
- Last Updated: November 13, 2023
- How we write
Highlights: The Most Important Gender Reassignment Surgery Statistics
Approximately 1.4 million adults in the U.S. identify as transgender.
As of 2019, 24% of trans women and 8% of trans men in the U.S have had at least one gender-affirming surgery.
In 2018, 2,052 gender reassignment surgeries were performed in the United States, compared to just 770 in 2000.
Nearly 50% of transgender individuals have reported seeking out hormone treatment.
In the UK, there has been a 240% increase in gender confirmation surgeries over the last five years (up to 2020).
54% of the transgender population in Europe have undergone gender reassignment surgery, while 34% are planning or seriously considering undergoing surgery.
According to the 2015 US Transgender Survey, 33% of respondents had undergone some form of gender transition related surgery.
About 14% of transgender women and 72% of transgender men do not want a complete gender reassignment.
As of 2020, Germany carries out the most gender reassignment surgeries in Europe at around 600 to 800 per year.
As per the 2016 studies, 61% of trans people in Mexico had undergone some type of transition-related surgery.
The average age of individuals seeking gender reassignment surgery in Australia is 39.
- Less than two thirds of American states (30 states) have laws that protect transgender people's access to transition-related healthcare in 2021.
The number of gender reassignment procedures conducted in Iran is more than in any other nation except Thailand.
The satisfaction rate of trans women who underwent gender reassignment surgery is around 97%.
Approximately 25% of Australian transgender people have undergone surgery and about 60% have taken hormones.
More than 80% of people who self-identify as transgender in Korea have pursued hormone therapy.
In Spain, approximately 10% of transgender individuals have undergone some sort of gender reassignment surgery.
In Canada, between 0.5% and 2% of the population identify as transgender, and an estimate of approximately 20% of this population have undergone gender reassignment surgery.
Almost a third (31.6%) of the French transgender population have had surgical procedures related to their transition.
About 83% of transgender Austrians have undergone hormone treatment, while 43% had surgery.
Table of Contents
The world of gender reassignment surgery has deeply transformed over the years, thanks to advancements in medical science and societal acceptance of transgender individuals. Nevertheless, a multitude of questions, including prevalence, success rates, and post-operative satisfaction levels, still persist. This blog post dives into the comprehensive realm of gender reassignment surgery statistics, helping shed light on figures that reveal trends, illustrate the facts, and potentially demystify common misconceptions, thereby contributing towards greater understanding and acceptance.
The Latest Gender Reassignment Surgery Statistics Unveiled
Highlighting the figure of approximately 1.4 million adults in the U.S. who identify as transgender sets a compelling foundation for a blog post on Gender Reassignment Surgery Statistics. This metric not only visualizes the potential audience size interested in or affected by gender reassignment procedures but also encapsulates the spectrum of personal experiences and narratives driving the demand for such surgeries. The figure further illuminates the socio-medical implications of transgender healthcare, drawing attention to accessibility, affordability and social acceptance issues surrounding these procedures in the United States. This statistic, therefore, roots the conversation in tangible terms, enabling readers to better grasp the relevance and magnitude of the topic.
Highlighting the statistic that as of 2019, 24% of trans women and 8% of trans men in the U.S have pursued at least one gender-affirming surgery, serves as an essential insight into the progress of gender affirmation in the medical field. The disparity between the two percentages brings to light the unique experiences, decisions and challenges faced by trans men and women respectively in their journey of transition. Beyond just numbers, it conveys the greater socio-cultural issues at play, such as access to healthcare, societal acceptance, financial possibility and personal health decisions, all of which influence the steps someone might take in their gender transition. Crucially, it underscores just how integral gender-affirming surgeries are to the trans community, driving discussions and decisions in health policies, surgical advancements, and societal inclusivity.
Highlighting the growth in the number of gender reassignment surgeries from 770 in 2000 to 2,052 in 2018 offers a vibrant picture of not just the increasing societal acceptance of transgender individuals in the United States, but also the evolving medical capabilities in this sector. This augmenting trend signifies a growing acceptance and medical advancement, vital for anyone following this trajectory. This surge goes beyond mere numbers, it whispers stories of a transforming society willing to acknowledge diverse identities while underscoring the role of advancements in medical science and surgery in empowering such transformation.
Painting a nuanced picture of the journey many transgender individuals embark upon, the statistic - nearly 50% of transgender people have reported seeking out hormone treatment - stands as a vivid testament to the complexities underlying the transition process. Within the tapestry of a blog post dissecting Gender Reassignment Surgery Statistics, this fact, like an intricate thread, interweaves issues of accessibility, choice and necessity into the broader context. It underscores the reality of a pre-surgical phase which precedes, and sometimes replaces, surgical intervention, amplifying the understanding of a multi-faceted path of gender transition. With nearly one in two transgender persons engaging in hormone treatments, this statistic stresses a crucial part of the narrative often subdued by the dramatic discourse on surgeries, and challenges readers to contemplate a diverse range of experiences.
The surging figure of a 240% increase in gender confirmation surgeries in the UK over the last five years (up to 2020) paints a telling picture of an evolving societal landscape. It’s an echo of increased acceptance, understanding, accessibility and legislation that endorses such life altering procedures. This striking statistic highlight the magnitude of growing demand, and consequently, the need for the healthcare system to adapt and adequately serve this expanding demographic. In a nutshell, it prompts deeper conversation around trans healthcare and underscores the importance of integrating this dialogue into the wider discourse about gender reassignment surgeries.
In a blog post weaving together the narrative of Gender Reassignment Surgery Statistics, the fact that 54% of Europe's transgender population have already transitioned surgically offers a compelling testament to the frequency of these procedures, underlining the significance of this sector in the medical landscape. Consider the additional 34% seriously contemplating surgery, this statistic introduces an even more robust dimension of potential future growth. Not only does this data provide an understanding of the present situation but also offers a telescope into future trends, encapsulating the continuous journey of many transgender individuals towards alignment of their physical and psychological identities.
Reflecting upon the 2015 US Transgender Survey that illustrates a substantive 33% of respondents advancing through some form of gender transition related surgery provides a potent validation for the prevalence and momentum of gender reassignment surgeries in the United States. In the landscape of a blog post dedicated to Gender Reassignment Surgery Statistics, this figure brings a data-driven realness, grounding theoretical discussions in measurable reality, thereby enriching understanding of gender surgery norms and patterns. Therefore, it is not merely a fraction, but a humanized window into the experiences and decisions of a significant segment of the transgender community, enhancing the depth of our discourse on the subject.
Delving into the intricate narrative of gender reassignment, it becomes paramount to comprehend the individuality and diversity that resides within the transgender community. The aforementioned statistic - about 14% of transgender women and 72% of transgender men not desiring a complete gender reassignment - underpins the notion that gender identity is not strictly binary, nor is it a universal urge among transgender individuals to physically align themselves entirely with their identified gender. This striking contrast between transgender men and women reflects the complexity of personal desires linked to gender transition. Therefore, it underscores the necessity for society, medical practitioners, and policy makers to appreciate the multifaceted nature of gender reassignment, casting light on the broader spectrum of transgender experiences, needs and desires.
Highlighting Germany's prominent role in Europe's gender reassignment surgery scene meaningfully underscores the global dynamics and variations of this subject. The data not only demonstrates Germany's advanced medical infrastructure and possibly more accepting societal norms towards gender surgery, but it also paves the way for discussions on various factors such as legislation, healthcare funding, social acceptance, and patient migration among European countries. Therefore, by setting the benchmark high, Germany's example encourages potential growth in other nations while prompting insightful conversations around trans health and rights.
The very fabric of discussion stands embellished with the compelling revelation extracted from 2016 studies - a significant 61% of trans individuals in Mexico have opted for some form of transition-related surgery. This pivotal insight not only generates a broader understanding of the increasing acceptability and prevalence of gender reassignment surgeries but also radiates an important reflection on the willingness of trans individuals in Mexico to affirm their identities via medical transitions. Within a post examining gender reassignment surgery statistics, this forms a critical cornerstone, substantiating arguments with real-world evidence and simultaneously, highlighting the potential influences of cultural, societal, and medical contexts on such life-changing decisions.
Drawing attention to the average age of individuals seeking gender reassignment surgery in Australia being 39, significantly enables us to understand the demographic dynamics that play into gender transition decisions. This figure illuminates the culmination of personal journeys, struggles for identity validation, and requisite financial preparation. It’s a compelling lens through which we perceive not only the maturity of the decision-making involved, but also the social and psychological hurdles participants often navigate prior to seeking surgery. It brings an implicit narrative of persistence in the face of societal norms, offering a quantitative snapshot of emotional evolutions. Therefore, this number is a cornerstone in the edifice of our understanding of Gender Reassignment Surgery Statistics.
Less than two thirds of American states (30 states) have laws that protect transgender people's access to transition-related healthcare in 2021.
Highlighting that fewer than two thirds of American states (30 states) provide legislations that safeguard transgender people's access to transition-related healthcare in 2021, serves as a telling barometer of societal inclusion. In a discourse surrounding Gender Reassignment Surgery Statistics, this statistic is an integral indicator, unpicking not only the healthcare disparities confronted by transgender community, but also illustrating the legislative landscape within the United States. As such, it lays bare the journey still to be traversed to ensure unfettered access to gender reassignment healthcare, critical for many within the transgender sphere.
Unraveling the fabric of Gender Reassignment Surgery Statistics in a global context, the noteworthy observation that Iran, a country painted with conservative brush strokes, holds the second-highest number of such procedures next to Thailand, presents an intriguing paradox. This piece of data opens a fascinating discourse on the intersection of gender, culture, religion, and state policies, shattering preconceived notions of where progressiveness in acceptance of gender transition lies geopolitically. It compels reflections, enriches our understanding of the complex dynamics in different societies, and invigorates discussions on the trajectory of transgender healthcare worldwide in the blog post.
Illuminating the narrative surrounding gender reassignment, the striking statistic of a 97% satisfaction rate amongst trans women post-surgery unveils a story of change and conclusively successful outcomes. In the expansive blog post dedicated to Gender Reassignment Surgery Statistics, this significant figure punctuates the discourse, underscoring not only the medical procedure's efficacy and safety but the affirmative, often life-altering, repercussions for individuals journeying through a gender transition. This potent statistic, a testament to medical advancements and societal acceptance, brings to life the overarching theme of courage, transformation and personal fulfillment.
Delving into the multifaceted narrative of gender transition, this particular survey highlights the distinct paths that Australian transgender individuals embarking on this journey may tread. Approximately one in four have opted for surgical realignment, a fraction that underscores the importance of safe and accessible surgical procedures within the healthcare system. Moreover, the statistic also reveals a substantially larger group, around 60%, who have embraced hormone treatment methods. This underlines the need for further research and resources devoted to hormone therapy and its impacts. This quantitative snapshot not only encompasses the diversity and individuality within the Australian transgender community's transition paths, but also pinpoints critical areas of healthcare that should be the focal point of medical and societal attention.
Shedding light on the narrative of gender transitioning in the Korean landscape, the statistic revealing that over 80% of transgender individuals have pursued hormone therapy plays a vital role. It underscores the prevalence of hormone therapy as a transitory stage toward gender reassignment surgery, a consideration often weighed in tandem with surgical procedures. Furthermore, it showcases the emphasis the transgender community places on hormonal intervention as a step in aligning their physical form with their gender identity. Thus, this statistic is instrumental in comprehending the larger journey and challenges within the transgender medical transition process, in a country stereotypically viewed as conservative on such matters.
Illuminating the landscape of gender affirming procedures, the statistic that approximately 10% of transgender individuals in Spain have embraced gender reassignment surgery serves as a cornerstone in our understanding. In a blog post tackling Gender Reassignment Surgery statistics, this number lets us delve deeper into the roadmaps of sociocultural acceptance, medical advancement, and personal choice. It provides a gauge of how many transgender individuals are accessing and opting for such surgeries in Spain, shedding light on the potential factors driving or hindering this decision, such as health policies, societal stigma, or economic resources. Beyond just digits, it paints a picture of real lives and real stories, playing an essential role in directing future discussions, policies and support systems.
In the realm of discourse on gender reassignment surgery, the Canadian statistic signifies a significant narrative. A slice of the populace, between 0.5% and 2%, identifying as transgender translates to a substantial number in a country with millions of residents. When we delve deeper to discover that roughly 20% of this group have pursued gender reassignment surgery, it characterizes the extent of surgical intervention in trans populations. This statistic not only adds weight to the dialogue around access to, and effectiveness of, such surgeries, but it spurs further questions regarding the remaining 80% and potential barriers they may face. Therefore, these figures add depth and perspective to the broader understanding of the intersection between transgender identities and surgical transition processes in Canada.
This compelling figure of 31.6% indicates an important trend within the French transgender community, showcasing the extent to which surgical procedures are sought after in their transition process. In a landscape intricate with personal decisions and societal challenges, this statistic provides a quantitative lens into the domains of gender identity and healthcare. Highlighting the frequency of gender reassignment surgeries within this demographic in France, it underscores the importance of open dialogue, societal awareness, and continued research to better understand, support and facilitate the needs and rights of the transgender population in the sphere of medical interventions.
Highlighting the statistic that about 83% of transgender Austrians have undergone hormone treatment, and 43% had surgery, underlines the extent of medical interventions that transgender individuals navigate in the pursuit of gender congruity. This data, in the context of a blog post about Gender Reassignment Surgery Statistics, amplifies the discourse about prevalent medical routes undertaken by transgender people, hence painting an informative picture of the transgender experience. This statistic is not just a number; it's a testament to the lengths individuals will go to assert their true identity, and a telling commentary on the healthcare and psychological support systems that need to be in place to support them.
According to the statistics assessed in this blog post, there's clear evidence of an upward trend in the number of gender reassignment surgeries being performed globally. This upward trajectory sheds light on the increasing acceptance and accessibility of such procedures, encouraging the transgender community towards their desired transitions. However, disparities exist in regions or income groups, reflecting the necessity for policy interventions towards cost-effectiveness and universal health coverage. Ultimately, these statistics highlight the need for further research and public policy interventions to break down barriers to gender reassignment surgeries.
0. - https://www.www.gires.org.uk
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16. - https://www.www.plasticsurgery.org
Frequently Asked Questions
What exactly is gender reassignment surgery, how effective or successful is gender reassignment surgery, are there risks or complications associated with gender reassignment surgery, what is the recovery process after gender reassignment surgery like, does gender reassignment surgery affect a person's fertility.
We have not conducted any studies ourselves. Our article provides a summary of all the statistics and studies available at the time of writing. We are solely presenting a summary, not expressing our own opinion. We have collected all statistics within our internal database. In some cases, we use Artificial Intelligence for formulating the statistics. The articles are updated regularly. See our Editorial Guidelines .
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In Texas, a Fight Over Gender and School Theater Takes an Unexpected Turn
After a high school production of “Oklahoma!” was halted in conservative Sherman, Texas, something unusual happened: The school board sided with transgender students.
By J. David Goodman
Reporting from Sherman, Texas
A school district in the conservative town of Sherman, Texas, made national headlines last week when it put a stop to a high school production of the musical “Oklahoma!” after a transgender student was cast in a lead role.
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The district’s administrators decided, and communicated to parents, that the school would cast only students “born as females in female roles and students born as males in male roles.” Not only did several transgender and nonbinary students lose their parts, but so, too, did cisgender girls cast in male roles. Publicly, the district said the problem was the profane and sexual content of the 1943 musical.
At one point, the theater teacher, who objected to the decision, was escorted out of the school by the principal. The set, a sturdy mock-up of a settler’s house that took students two months to build, was demolished.
But then something even more unusual happened in Sherman, a rural college town that has been rapidly drawn into the expanding orbit of Dallas to its south. The school district reversed course. In a late-night vote on Monday, the school board voted unanimously to restore the original casting. The decision rebuked efforts to bring the fight over transgender participation in student activities into the world of theater, which has long provided a haven for gay, lesbian and transgender students, and it reflected just how deeply the controversy had unsettled the town.
The district’s restriction had been exceptional. Fights have erupted over the kinds of plays students can present , but few if any school districts appear to have attempted to restrict gender roles in theater. And while legislatures across the country, including in Texas, have adopted laws restricting transgender students’ participation in sports, no such legislation has been introduced to restrict theater roles, according to the National Conference of State Legislatures.
The board’s vote came after students and outraged parents began organizing. In recent days, the district’s administrators, seeking a compromise, offered to recast the students in a version of the musical meant for middle schoolers or younger that omitted solos and included roles as cattle and birds. Students balked.
After the vote, the school board announced a special meeting for Friday to open an investigation and to consider taking action against the district superintendent, Tyson Bennett, who oversaw the district’s handling of “Oklahoma!,” including “possible administrative leave.”
Suddenly, improbably, the students had won.
“I’m beyond excited and everyone cried tears of joy,” Max Hightower, the transgender senior whose casting in a lead role triggered the ensuing events, said in a text message on Tuesday. He and other theater students were at a costume shop on Tuesday, a class trip that had been meant as a consolation after the disappointment of losing their production. Instead, it turned into a celebration. “I’m getting new Oklahoma costumes!!” he said.
Before the school board vote Monday night, high schoolers and their parents had gathered at the district’s offices along with theater actors and transgender students from nearby Austin College. Local residents came to talk about decades of past productions at Sherman High School of “Oklahoma!,” which tells the story of an Oklahoma Territory farm girl and her courtship by two rival suitors. Many scoffed at the district’s objections to the musical, which school officials complained included “mature adult themes.”
“‘Oklahoma!’ is generally regarded as one of the safest shows you could possibly pick to perform,” said Kirk Everist, a theater professor at Austin College who was among those who came to speak. “It’s almost a stereotype at this point.”
Every seat in the room was filled, almost entirely with supporters of the production. Some lined the walls while others who were turned away waited outside. Of the 65 people who signed up to speak, only a handful voiced support for the district’s restrictions.
The outpouring came as a shock, even to longtime Sherman residents.
“What you’re seeing today is history,” said Valerie Fox, 41, a local L.G.B.T.Q. advocate and the parent of a queer high schooler. Ms. Fox said she was taken aback by the scene of dozens of transgender people and their supporters holding signs and flags outside the district offices. “This is one of the biggest things we’ve seen in Sherman.”
The town, a short drive from Dallas, has been a place where many conservatives have gone to escape the city. Some were supportive of the superintendent’s initial decision to restrict the musical.
“Adult content doesn’t belong in high school; they’re still kids,” Renée Snow, 62, said earlier on Monday as she sat with her friend on a bench outside the county courthouse. “It’s about education. It’s not about lifestyle.”
Her friend, Lyn Williams, 69, agreed. “It doesn’t seem like anyone is willing to stand up for anything anymore,” she said.
At a local shoe store, no one needed to be reminded of the details of the controversy. One shopper, shaking a pair of insoles, said that she believed that God made people either male or female, and that the issue was a simple as that.
Inside the courthouse, Bruce Dawsey, the top executive for Grayson County, described a rural community coming to terms with its evolution into a place where urban development is altering the landscape. Not far away, more than a half-dozen cranes could be seen towering over a new high-tech facility for Texas Instruments . The high school, with more than 2,200 students, opened on a sprawling new campus in 2021, its grass still uniform, its newly planted trees still struggling to provide shade. With all the growth, the school is already too small.
“The majority is Republican, and it’s conservative Republican,” Mr. Dawsey said. “But not so ultraconservative that it’s not welcoming.”
Still, some in and around Sherman have chafed at the changes. When Beto O’Rourke, a Democratic candidate for governor, campaigned through the county last year, he was met with aggressive protesters who confronted him over gun rights , some carrying assault-style rifles. A few wore T-shirts suggesting opposition to liberal urban governance: “Don’t Dallas My Grayson County.”
But the controversy over “Oklahoma!” came as a surprise. The musical had been selected and approved last school year, casting was completed in August and more than 60 students in the cast and crew — as well as dozens of dancers — had been preparing for months. Performances were scheduled for early December.
Max, 17, had been cast in a minor role. But then, in late October, one of the leads was cut from the production, and Max got the part, the biggest he had ever had. He was elated.
Days later, his father, Phillip Hightower, got a call from the high school principal, who told him that Max could not have the part because, under a new policy, no students could play roles that differed from their sex at birth. “He was not rude or disrespectful, but he was very curt and to the point,” Mr. Hightower recalled.
The district later denied having such a policy. But the principal also left messages for other parents whose children were losing their roles, one of which was shared with The New York Times.
“This is Scott Johnston, principal at Sherman High School,” a man’s voice said on the recording. “Moving forward, the Sherman theater department will cast students born as females in female roles and students born as males in male roles.”
The message diverged from the rules for high school theater competitions in Texas , which allow for students to be cast in roles regardless of gender.
The district did not make Mr. Johnston or the superintendent, Mr. Bennett, available for an interview.
In his previous role as an assistant superintendent, Mr. Bennett had objected to the content of a theater production by Sherman High School, according to the former choir director, Anna Clarkson. She recalled Mr. Bennett asking her to change a lesbian character into a straight character in the school’s production of “Legally Blonde” in 2015, and to cut a song entitled “Gay or European?”
At the school board meeting on Monday, theater students from the high school described how things had become worse for gay and transgender students at school since the production was halted. Slurs. Taunts. Arguments in the halls.
“People are following me around calling me girl-boy,” said Max.
Kayla Brooks and her wife, Liz Banks, arrived at the meeting bracing for a tough night. Their daughter Ellis had lost a part playing a male character, and they had been actively working with other parents to oppose the changes.
“We were both nervous, because we live in Sherman,” said Ms. Banks. Then they saw the large, supportive crowd outside. “We began weeping in the car,” Ms. Brooks said.
The school board sat mostly stone-faced as dozens of people testified in support of the theater students, sharing personal histories. A transgender student at Austin College said he had not before come out publicly. Sherman residents lamented the way the school district’s position had made the town look.
“I just want this town to be what it can be and not be a laughingstock for the entire nation,” one woman, Rebecca Gebhard, told the board.
After nearly three hours, the board went behind closed doors. The crowds left. Few expected a significant decision was imminent.
Then, after 10 p.m., the board took their seats again and introduced a motion for a vote: Since there was no official policy on gender for casting, the original version of the musical should be reinstated. All seven board members voted in favor, including one who had, months before, protested against a gay pride event.
“We want to apologize to our students, parents, our community regarding the circumstances that they’ve had to go through,” the board president, Brad Morgan, said afterward.
Sitting in their living room on Tuesday morning, Ms. Banks and Ms. Brooks recalled how their daughter delivered them the news. “She just said, ‘We won,’” Ms. Brooks said. “She was beaming, smiling ear to ear.” The musical would be performed in January.
The couple decided, for the first time, to hang a pride flag in the window of their home. For now, they felt a little more confident in their neighbors than they had a day before.
Alain Delaquérière contributed research.
Audio produced by Tally Abecassis .
J. David Goodman is the Houston bureau chief, covering Texas. He has written about government, criminal justice and the role of money in politics for The Times since 2012. More about J. David Goodman
Trump Sparks Debate with Controversial Remarks About LeBron James, Suggesting Gender Reassignment Surgery in Bizarre Statement
Posted: November 15, 2023 | Last updated: November 15, 2023
Trump has caused a debate once again by mocking LeBron James. Trump has been targeting the popular athlete ever since LeBron disagreed with Trump’s political views in 2020. True to form, Trump’s comments are raising eyebrows online.
Trump Raises Eyebrows
Donald Trump’s latest speech raises eyebrows with unexpected comments about basketball player LeBron James and sex change surgery.
A New Controversy
Former US president Donald Trump has always been known for his unconventional statements, but his recent remarks have left many surprised.
Gender Change Speech
During a lengthy speech in Phoenix, Arizona, Trump suggested that LeBron James should undergo gender reassignment surgery to join a women’s sports team.
A Surprising Suggestion
Trump shared his thoughts during the rally, suggesting that LeBron James would have a better chance of winning if he had a gender change operation and competed on women’s teams instead.
Trump’s Controversial Coaching
Trump also sarcastically said that if he were coaching a female sports team, he would only recruit transgender athletes in a bizarre rant.
Trump’s Strange Approach
“I wouldn’t be talking to too many women as we know women. I’d be getting some of these people that they’re women,” Trump rambled.
Poking Fun at LeBron
Trump continued by poking fun at LeBron James, “Did you see the basketball ratings they were terrible, but they went up after his team were defeated.”
Clarification on James’ Identity
LeBron James has never expressed a desire to undergo gender reassignment surgery, and he identifies as male.
Trump’s History With Lebron James
This isn’t the first time Trump has directed remarks at James! He previously criticized James and other players for boycotting playoff games in 2020 during Trump’s reign as president.
Black Lives Matter Debate
The boycott came after the police shot yet another black man. Trump defended the police involved in the incident.
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Watch CBS News
How gender disparities are affecting men
By Lee Cowan
November 12, 2023 / 9:10 AM EST / CBS News
At the University of Vermont not long ago, it was move-in day for the class of 2027. About a thousand incoming freshman were meeting their roommates, finding their dorm rooms, and getting settled on campus. At first glance one might have thought this was an all-women's college – 62% of this year's class are women, a gender gap that has earned Burlington, Vt., a nickname: Girlington.
"You see six or seven women for every three or four men," said UVM's vice provost for enrollment Jay Jacobs. His job is all about student diversity, and these days the male/female divide is now part of that equation. "Sure, I thought about racial and ethnic diversity," Jacobs said. "Sure, at a public flagship in the state of Vermont, I've thought about geographic diversity. Never gender diversity like that. That's where we are."
UVM is hardly an outlier. Nationwide, women make up almost 60% of college undergraduates.
In 1972, when Title IX was passed to help improve gender equality on campus, men were 13% more likely to get an undergraduate degree than women; today, according to the National Center for Education Statistics, it's women who are 15% more likely to get a degree than men.
"We have a bigger gender gap today than we did when we passed laws to help women and girls; it's just flipped," said Richard Reeves, a former Brookings Institution senior fellow. He says, no one really has been able to explain why so many men are so absent in higher education. What is known is the gender disparity starts as early as kindergarten, where girls are just generally the stronger sex in academics.
Reeves said, "If you look at high school GPA, and those who are getting the best grades in high school, two-thirds of them are girls. Those with the lowest grades, two-thirds of them are boys."
It's been theorized girls and women today are just fulfilling their destiny – that once the limitations on their achievements were lifted, they soared. Reeves, who's just launched the American Institute for Boys and Men, fears that things have changed so quickly, it's left many boys and men struggling to catch up, not just in the classroom, but at work and at home, too.
"What does it mean to be a successful man today? That was a question that was pretty easy to answer a generation or two ago," said Reeves. "But actually, what is the answer today? A lot of these guys just don't know."
In short, he says millions of boys and men don't understand how or where they fit anymore, and their reaction is to generally disconnect. According to the U.S. Bureau of Labor Statistics, men's participation in the labor market has dropped more than 7% in the last 50 years. According to the Centers for Disease Control and Prevention, 21% of men report binge drinking (almost double the rate of women), and men account for nearly 80% of suicide deaths (four times the rate for women).
Reeves said, "The two most commonly-used words by suicidal men to describe themselves were useless and worthless ."
But even to suggest there's some kind of male crisis is perilous these days, said Reeves: "Merely raising it will cause people to eye roll, and say, 'Really? Ten thousand years of patriarchy, and now you're worried?'"
After all, women still earn only about 80 cents for every dollar earned by a man (according to Pew Research Center). Only a fraction (10.4%) of Fortune 500 CEOs are women. And women make up just a quarter (28%) of the members in Congress, and (so far) zero U.S. presidents.
Those numbers leave UVM students Sarah Wood and Maxine Flordeliza pretty skeptical that men are barely treading water. "I think it's very interesting that there is kind of a big fuss about – not a fuss, but it's a conversation that people are having," said Wood. "But I don't think it's necessarily a problem?"
"I think that just the fact that the playing field has been a bit more evened out, shouldn't be the reason as to why men don't really know where they fit," Flordeliza said.
"Sure, do we need to do more to encourage more women into politics and into board rooms? Yes," Reeves said. "But meanwhile, can I not see that one group is struggling here, and another group is struggling there? And if I can't do that, we're in really deep trouble."
And those in the most trouble, he says, are working class and African American boys and men.
Von Washington Jr., executive director of community relations with The Kalamazoo Promise in Michigan, said, "Before it used to be, you graduated high school, 'Goodbye, you're on your own.' A lot of people said, 'Hey, you're outta my house.' Or 'It's time for you to go.' But we're understanding now those supports need to continue."
The Kalamazoo Promise program offers high school graduates in Kalamazoo scholarships covering up to the entire cost of in-state college tuition. The impact? The number of Kalamazoo women getting a college degree has increased by about 45%. But the number of Kalamazoo men getting college degrees didn't budge.
"We're working with them, we're talking with them," said Washington. "We're trying to find out what is it that, even with this opportunity, you have some of the same challenges as someone in another community that doesn't have this opportunity."
One solution that seems to be working is making sure those men who are struggling have a place to freely admit they're struggling. Staffers with The Promise are tracking down those men still eligible for the scholarship, finding out why they never used it, and helping them get what they need to finally do it – like Daniel Jaffari. "I just started wandering around in life and doing random jobs, getting tired of doing random jobs," said Jaffari. "And now I'm here!"
He joined with dozens of other men at what the Promise was calling their Males of Promise event. Another participant was Denis Martin, who graduated high school six years ago. He said, had the Promise not tracked him down, he might not have realized he was ready for something more. "I feel like now I have the discipline to be in a five-year program or a four-year program," he said. "As a kid I feel like I was still bouncing off the walls, and my mind didn't know what exactly was out there."
Back at UVM, administrators have changed their marketing and communication strategies to reach out to men, especially those who might not think they want to go to college at all. The college is also hiring a diversity coordinator to focus specifically on helping men.
Jacobs said to Cowan, "The world is built for people like you and me to succeed, so why do we need to help men succeed here on our campus even more? But I think once people start to understand the nuances and challenges that we're talking about here today, people understand that all students need support."
UVM junior Lucas Roemer doesn't see it as a sort of affirmative action – putting the finger on the scale for men. He sees it as a way to help anyone who's been hanging on and feeling left out. "I think there's ways to promote both femininity and masculinity on campus equally well," he said. "I think there's definitely a path forward that could be beneficial to everybody."
The coordinator of the Men and Masculinities Program will be housed in the Women & Gender Equities Center – ironic to some. But it's also a recognition that men's problems can co-exist with those of women. "You lift the edges up, the center will be lifted up as well," said Jacobs. "And here, the edges include men."
It's the kind of reaction to the very real problems of boys and men that Richard Reeves says needs to be the rule, and not the exception: "This is not a made-up crisis of masculinity. This is an actual hard fact. There is real suffering here, and if we don't address real suffering, then what are we here for?"
For more info:
- "Of Boys and Men: Why the Modern Male Is Struggling, Why It Matters, and What to Do About It" by Richard V. Reeves (Brookings Institution Press), in Hardcover, eBook and Audio formats, available via Amazon , Barnes & Noble and Bookshop.org
- Richard Reeves on the American Institute for Boys and Men
- University of Vermont (UVM) , Burlington, Vt.
- The Kalamazoo Promise , Kalamazoo, Michigan
Story produced by Mark Hudspeth. Editor: Mike Levine.