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Satisfaction with male-to-female gender reassignment surgery, results of a retrospective analysis, hess, j ; neto, r r ; panic, l ; rübben, h ; senf, w.

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Background : The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery.

Methods : 254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital’s Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction.

Results : 119 (46.9%) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1–7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now.

Conclusion : The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.

Culturally, gender is considered an obvious, unambiguous dichotomy. The term “gender identity” denotes the consistency of one’s emotional and cognitive experience of one’s own gender and the objective manifestations of a particular gender. In gender identity disorder, one’s own anatomical sex is objectively perceived but is felt to be alien, whereas the term “gender incongruence” refers to a difference between an individual’s gender identity and prevailing cultural norms. Finally, gender dysphoria is the suffering that results. The treatment guidelines of the World Professional Association of Transgender Health (WPATH) state that gender identity need not coincide with anatomical sex as determined at birth. Transgender identity should therefore be considered neither negative nor pathological ( 1 ). Unfortunately, gender incongruence often leads to discrimination against the affected individual, which can favor the development of psychological complaints such as anxiety disorders and depression ( 2 – 4 ). While some transgender individuals are able to realize their gender identity without surgery, for many gender reassignment surgery is an essential, medically necessary step in the treatment of their gender dysphoria ( 5 ). Research conducted to date has shown that gender reassignment surgery has a positive effect on subjective wellbeing and sexual function ( 2 , 6 , 7 ). The surgical procedure (penile inversion with sensitive clitoroplasty) is described in eBox 1.

No official figures are available on the prevalence of transgender or gender-nonconforming individuals, and it is very difficult to arrive at a realistic estimate. There is no central reporting register in Germany. Furthermore, figures for those who seek medical help for gender dysphoria would in any case give only an imprecise idea of the true prevalence. The global prevalence of transgender individuals has been estimated at approximately 1 per 11 900 to 1 per 45 000 for male-to-female individuals and approximately 1 per 30 400 to 1 per 200 000 for female-to-male individuals ( 1 ). Weitze and Osburg estimate prevalence in Germany at 1 per 42 000 ( 8 ). In contrast, De Cuypere et al. ( 9 ) suppose a prevalence of 1 per 12 900 for Belgium. Biosnich et al. ( 10 ) estimate prevalence among US veterans at 1 per 4366. This compares to an estimated prevalence of 1 per 23 255 in the general population. Even if percentages of transgender individuals in different parts of the world are comparable, it is highly likely that cultural differences will lead to differing behavior and expression of gender identity, resulting in differing levels of gender dysphoria ( 1 ). The ratio of male-to-female to female-to-male transgender individuals varies greatly. Although it was given as approximately 3:1 by van Kesteren ( 11 ), it is 2.3:1 according to Weitze and Osburg ( 8 ) and 1.4:1 according to Dhejne ( 3 ). Garrels ( 12 ) found a gradual decrease in the difference between the two figures in Germany, with the ratio decreasing from 3.5:1 (in the 1950s and 60s) to 1.2:1 (1995 to 1998) (Table 1).

Criteria for diagnosis

Transsexualism is primarily a problem of gender identity (transidentity) or gender role (transgenderism) rather than of sexuality ( 13 ). In Germany, it is diagnosed according to ICD-10 (10 th revision of the International Statistical Classification of Diseases and Related Health Problems).

Criteria for diagnosis include the following:

• Feeling of unease or not belonging to biological gender
• Desire to live and be accepted as a member of the opposite sex
• Presence of this desire for at least two years persistently
• Wish for hormonal treatment and surgery
• Not a symptom of another mental disorder
• Not associated with intersex, genetic, or gender chromosomal abnormalities.

Psychological aspects of transsexualism

According to Senf, no disruption to an individual’s identity is comparable in scale to the development of transsexualism ( 14 ). Transsexualism is a dynamic, biopsychosocial process which those affected cannot escape. An affected individual gradually becomes aware that he or she is living in the wrong body. The feeling of belonging to the opposite sex is experienced as an unchangeable, unequivocal identity ( 14 , 15 ). The individual therefore strives to change his or her inner identity. This change is associated with a change in psychosocial role, and in most cases with hormonal and/or surgical reassignment of the body to the desired gender ( 14 ). Coping with the development of transsexualism poses enormous challenges to those affected and often leads to a considerable psychological burden. In some cases this results in mental illness. Transsexualism itself need not lead to a mental disorder ( 14 ). Psychotherapeutic support is beneficial and is a major part of standard treatment and the examination of transsexual individuals in Germany ( 15 ).

This study aimed to evaluate the effect of male-to-female gender reassignment surgery on the satisfaction of transgender patients.

Data collection

Retrospective inquiry involved consecutive inclusion of 254 patients who had undergone male-to-female gender reassignment surgery involving penile inversion vaginoplasty at Essen University Hospital’s Department of Urology between 2004 and 2010. All patients received a questionnaire (eBox 2) by post, with a franked return envelope. The questions were contained within a follow-up questionnaire developed by Essen University Hospital’s Department of Urology ( 16 ). Because the process was anonymized, patients who had not sent back the questionnaire could not be contacted. The diagnosis of “transidentity” had been made previously following specialized medical examination and in accordance with ICD-10.

Statistical evaluation was performed using SPSS (Statistical Package for the Social Sciences, 17.0). Correlation analyses were performed using SAS (Statistical Analysis System, 9.1 for Windows). The distribution of categorical and ordinal data was described using absolute and relative frequencies. Fisher’s exact test was used to compare categorical and ordinal variables in independent samples. The Mann–Whitney U-test was used to compare satisfaction scale distribution of two independent samples. This nonparametric test was used in preference to the t-test because the Shapiro–Wilk test indicated that distribution was not normal. Spearman’s correlation analysis was performed.

A total of 119 completed questionnaires were returned, all of which were included in the evaluation. This represents a response rate of 46.9%. Because the questionnaires were anonymous, no data on patients’ ages could be obtained. The average age of a comparable cohort of patients at Essen University Hospital’s Department of Urology between 1995 and 2008 ( 17 ) was 36.7 years (16 to 68 years). The median time since surgery was 5.05 years (standard deviation: 1.6 years; range: 1 to 7 years). Not all patients had completed the questionnaire in full, so for some questions the total number of responses is not 119.

Following surgery, 63 of 103 patients (61.2%) were satisfied with their outward appearance as women, and a further 27 (26.2%) were very satisfied (Figure 1). 45.5% (n = 50) were very satisfied with the gender reassignment surgery process, 30% (n = 33) satisfied, 22.7% (n = 25) mostly satisfied, and 1.8% (n = 2) dissatisfied. Figure 2 shows the high rates of subjective satisfaction with the aesthetic outcome of surgery. Overall, approximately three-quarters (70 of 94 responses) reported that they were satisfied or very satisfied. A further 21 (22.3%) were mostly satisfied. Figures for satisfaction with the functional outcome of surgery were similar (Figure 3). A total of 67 of 93 respondents (72%) were satisfied or very satisfied. A further 18 patients (19.4%) were mostly satisfied. Table 2 compares the rates of subjective satisfaction with aesthetic and functional outcome with other studies.

In order to gather information on patients’ general satisfaction with their lives, they were asked to place themselves on a Likert scale ranging from 1 (“very dissatisfied”) to 10 (“very satisfied”). Of the total of 102 respondents, 7 (6.9 percent) selected scores from 1 to 3 (2 × 1, 1 × 2, 4 × 3) and 39 (38.2%) scores from 4 to 7 (4 × 4, 16 × 5, 8 × 6, 11 × 7). 56 patients (54.9%) placed themselves in the top third (32 × 8, 13 × 9, 11 × 10). 88 of 103 participants (85.4%) felt completely female following surgery, and 11 (10.7%) mostly female (Figure 4). 69 of 102 women (67.6%) saw themselves as fully accepted as women by society, 25 (24.5%) mostly, and 6 (5.9%) rarely. Two women (2.0%) were not sure of their answer to this question. Of 95 respondents, 65 (68.4%) answered with a clear “Yes” that their life had become easier since surgery. 14 (14.7%) found life somewhat easier, 9 (9.5%) somewhat harder, and 7 (7.4%) harder. Expectations of life as a woman were completely fulfilled for 51 of 102 (50.0%) women, and mostly for 41 (40.2%). The expectations of 6 (5.9%) patients were mostly not fulfilled, and those of 4 (3.9%) were not fulfilled at all.

There was a correlation between self-perception as a woman (“How do you see yourself today?”) and perceived acceptance by society (r = 0.495; p <0.01). There was also a correlation between self-perception and answers to whether life had become easier since surgery (r = 0.375; p <0.01) and whether expectations of life as a woman had been fulfilled (r = 0.419; p <0.01). Patients who saw themselves completely as women reported higher scores for current satisfaction with their lives than patients who only saw themselves as more female than male (r = 0.347; p <0.01).

Patients were asked how easy they found it to achieve orgasm. A total of 91 participants answered this question: 75 (82.4%) reported that they could achieve orgasm. Of these, 19 (20.9%) still achieved orgasm very easily, 39 (42.9%) usually easily, and 17 (18.7%) rarely easily. Participants were also asked to compare their experience of orgasm before and after surgery (more intense/the same/less intense). Over half of those who answered this question (43 of 77, 55.8%) experienced more intense orgasm postoperatively, and 16 patients (20.8%) experienced the same intensity.

According to Sohn et al. ( 18 ), subjective satisfaction rates of 80% can be expected following gender reassignment surgery. Löwenberg ( 19 ) reported 92% general satisfaction with the outcome of gender reassignment surgery. The study by Imbimbo et al. ( 20 ) found a similarly high satisfaction rate (94%); however, subjective assessment of general satisfaction and the question of whether or not patients regretted the decision to undergo gender reassignment surgery were queried in one combined question. It is likely that most patients do not actually regret their decision to undergo surgery, even though general postoperative satisfaction is limited. Löwenberg’s figures also show this ( 19 ): 69% of those asked were satisfied with their overall life situation, but 96% would opt for surgery again. In the authors’ own study population, general satisfaction with surgery was achieved in 87.4% of patients. Regardless of surgical results, over half of patients (54.9%) were in the top third (“completely satisfied”) and a further 38.2% in the middle third (“fairly satisfied”) of the general life satisfaction scale.

A retrospective survey performed by Happich ( 21 ) found more than 90% satisfaction with gender reassignment. Sexual experience following surgery is a very important factor in satisfaction with gender reassignment. It depends essentially on the functionality of the neovagina. Figures for satisfaction with functional outcome range from 56% to 84% ( 16 , 19 , 20 , 22 , 23 ). In the authors’ population, satisfaction with function was 72% (“very satisfied” and “satisfied”) or 91.4% (including also “mostly satisfied”). According to Happich ( 21 ), satisfaction with sexual experience is positively correlated with satisfaction with outcome of surgery. Other studies ( 16 , 23 – 25 ) have also found surgical outcome to be one of the essential factors in postoperative satisfaction. Löwenberg ( 19 ) also found a correlation between satisfaction with surgery and satisfaction with aesthetic appearance of the external genitalia. In our study, almost all patients (98.2%) were satisfied with the gender reassignment surgery process (n = 50, 45.5% “very satisfied”; n = 33, 30% “satisfied”; n = 25, 22.7% “mostly satisfied”).

The Imbimbo et al. working group ( 20 ) reported 78% satisfaction with aesthetic appearance of the neogenitalia (36% “very satisfied,” 32% “satisfied,” 10% “mostly satisfied”). Happich found 82.1% satisfaction with outcome of surgery (46 of 56 patients). Of these, 33.9% of patients reported high satisfaction and 48.2% good to medium satisfaction ( 21 ). A similar value was obtained in the survey by Hepp et al. ( 22 ). Löwenberg ( 19 ) found higher values (94%) for satisfaction with aesthetic outcome of surgery. This population included 106 male-to-female transgender individuals who underwent surgery at Essen University Hospital’s Department of Urology between 1997 and 2003. In the population described here (254 patients, 2004 to 2010) satisfaction with aesthetic outcome was still higher (96.8%).

Orgasm was possible for 82.4% of study participants. The ability to achieve orgasm was lower than in an earlier study population ( 16 ). Figures in the literature vary widely (29% to 100%) and sometimes include small case numbers (Table 3). Overall, the figures for this study match those of comparable studies of a similar size. Finally, it is not clear why more than half the participants experienced orgasm more intensely following surgery than preoperatively. One possible explanation is that postoperatively patients were able to experience orgasm in a body that matched their perception.

Limitations

The response rate of less than 50% must be mentioned as a shortcoming of this study. This may have led to a bias in the results. If all patients who did not take part in the survey were dissatisfied, up to 50.1% and 54.6% would be dissatisfied with aesthetic or functional outcome respectively. According to Eicher, the suicide rate in transgender individuals following successful surgery is no higher than in the general population ( 26 ), so suicide is a very unlikely reason for nonparticipation. Contacting transfemale patients for long-term follow-up after successful surgery is generally difficult ( 2 , 3 , 22 , 23 , 25 , 27 , 28 ). This may be because a patient has moved since successful surgery, for example, ( 21 ). Postoperative contact is particularly difficult in countries such as Germany which have no central registers. Response rates to surveys in retrospective research are between 19% ( 28 ) and 79% ( 29 ). Goddard et al. obtained a response rate of 30% in a retrospective survey following gender reassignment surgery ( 30 ). A follow-up survey performed by Löwenberg et al. had a similar response rate, 49% ( 19 ). It is also possible that the positive results of our survey represent patients’ wish for social desirability rather than the real situation. However, this cannot be verified retrospectively.

Taking into account the limitations mentioned above, the high rates of subjective satisfaction with outward female appearance and with aesthetic and functional outcome of surgery indicate that the study participants benefited from gender reassignment surgery.

Conflict of interest statement Dr. Hess has received reimbursement of conference fees and travel expenses from AMS American Medical Systems.

The other authors declare that no conflict of interest exists.

Manuscript received on 9 May 2014, revised version accepted on 25 August 2014.

Translated from the original German by Caroline Devitt, M.A.

Corresponding author: Dr. med. Jochen Hess Klinik für Urologie, Universitätsklinikum Essen Hufelandstr. 55 45122 Essen Germany [email protected]

@For eReferences please refer to: www.aerzteblatt-international.de/ref4714

eBoxes: www.aerzteblatt-international.de/14m0795

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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

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

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

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

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

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

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

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

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

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26 april 2011.

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

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

• Decreased antidepressant use
• Decreased anxiety, depression, and suicidal ideation
• Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

• Both a man and a woman
• Neither a man nor a woman
• An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

• Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
• Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
• Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

• Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
• Hysterectomy (uterus removal)
• Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
• Oophorectomy (ovary removal)
• Phalloplasty (surgery to create a penis)
• Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

• Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
• Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

• Constructing a glans (head) to look more like a penis
• Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
• Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

• Breast augmentation
• Facial feminization surgery
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
• Vaginoplasty
• Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

• Acute kidney injury
• Blood transfusion
• Deep vein thrombosis, which is blood clot formation
• Pulmonary embolism, blood vessel blockage for vessels going to the lung
• Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
• Surgical site infection
• Urethral stricture or stenosis, which is when the urethra narrows
• Urinary tract infection (UTI)
• Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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Germany passes law making it easier to legally change gender

The legislation allows under-18s to change their legal gender and first name with parental consent.

Germany's parliament passed a new law on Friday, easing legal procedures for changing names and gender identity. 

The 'Gender Identity Act' was widely supported by the ruling 'traffic light' coalition of Olaf Scholz, though debates were fiery and emotional. 

The final vote count was 374 in favour with 251 against. 

Before the new legislation - which comes into effect on 1 November - those applying to legally change gender needed the approval of two psychiatrists “sufficiently familiar with the particular problems of transsexualism.”

A court would then decide if the legal change was allowed.  

Now, under the new law, adults aged 18 and over only have to notify authorities three months before. Then it is a simple procedure to choose a new gender out of three existing options in German legislation. 

No further changes or undoes are allowed for a year.

For German citizens aged 14-18, such applications to change their first name or gender entry must be approved by parents and guardians. 

If they refuse, an applicant may address Family Court to override their say. For people under 14, parents or guardians must file a request in their name.

Public places, like gyms and dressing rooms, still have the right to decide whom they allow in.

The new law addresses only legal procedures and doesn't change gender-changing surgery rules.

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Readiness assessments for gender-affirming surgical treatments: A systematic scoping review of historical practices and changing ethical considerations

Travis amengual.

1 Department of Psychiatry and Behavioral Sciences, Northwestern Medicine, Chicago, IL, United States

Kaitlyn Kunstman

R. brett lloyd, aron janssen.

2 The Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States

Annie B. Wescott

3 Galter Health Science Library, Northwestern University, Chicago, IL, United States

Associated Data

The original contributions presented in this study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Transgender and gender diverse (TGD) are terms that refer to individuals whose gender identity differs from sex assigned at birth. TGD individuals may choose any variety of modifications to their gender expression including, but not limited to changing their name, clothing, or hairstyle, starting hormones, or undergoing surgery. Starting in the 1950s, surgeons and endocrinologists began treating what was then known as transsexualism with cross sex hormones and a variety of surgical procedures collectively known as sex reassignment surgery (SRS). Soon after, Harry Benjamin began work to develop standards of care that could be applied to these patients with some uniformity. These guidelines, published by the World Professional Association for Transgender Health (WPATH), are in their 8th iteration. Through each iteration there has been a requirement that patients requesting gender-affirming hormones (GAH) or gender-affirming surgery (GAS) undergo one or more detailed evaluations by a mental health provider through which they must obtain a “letter of readiness,” placing mental health providers in the role of gatekeeper. WPATH specifies eligibility criteria for gender-affirming treatments and general guidelines for the content of letters, but does not include specific details about what must be included, leading to a lack of uniformity in how mental health providers approach performing evaluations and writing letters. This manuscript aims to review practices related to evaluations and letters of readiness for GAS in adults over time as the standards of care have evolved via a scoping review of the literature. We will place a particular emphasis on changing ethical considerations over time and the evolution of the model of care from gatekeeping to informed consent. To this end, we did an extensive review of the literature. We identified a trend across successive iterations of the guidelines in both reducing stigma against TGD individuals and shift in ethical considerations from “do no harm” to the core principle of patient autonomy. This has helped reduce barriers to care and connect more people who desire it to gender affirming care (GAC), but in these authors’ opinions does not go far enough in reducing barriers.

Introduction

Transgender and gender diverse (TGD) are terms that refer to any individual whose gender identity is different from their sex assigned at birth. Gender identity can be expressed through any combination of name, pronouns, hairstyle, clothing, and social role. Some TGD individuals wish to transition medically by taking gender-affirming hormones (GAH) and/or pursuing gender-affirming surgery (GAS) ( 1 ). 1 The medical community’s comfort level with TGD individuals and, consequently, their willingness to provide a broad range of gender affirming care (GAC) 2 has changed significantly over time alongside an increasing understanding of what it means to be TGD and increasing cultural acceptance of LGBTQI people.

Historically physicians have placed significant barriers in the way of TGD people accessing the care that we now know to be lifesaving. Even today, patients wishing to receive GAC must navigate a system that sometimes requires multiple mental health evaluations for procedures, that is not required of cisgender individuals.

The medical and psychiatric communities have used a variety of terms over time to refer to TGD individuals. The first and second editions of DSM described TGD individuals using terms such as transvestism (TV) and transsexualism (TS), and often conflated gender identity with sexuality, by including them alongside diagnoses such as homosexuality and paraphilias. Both the DSM and the International Classification of Diseases (ICD) have continuously changed diagnostic terminology and criteria involving TGD individuals over time, from Gender Identity Disorder in DSM-IV to Gender Dysphoria in DSM-5 to Gender Incongruence in ICD-11.

In 1979, the Harry Benjamin International Gender Dysphoria Association 3 , renamed the World Profession Association for Transgender Health (WPATH) in 2006, was the first to publish international guidelines for providing GAC to TGD individuals. The WPATH Standards of Care (SOC) are used by many insurance companies and surgeons to determine an individual’s eligibility for GAC. Throughout each iteration, mental health providers are placed in the role of gatekeeper and tasked with conducting mental health evaluations and providing required letters of readiness for TGD individuals who request GAC ( 1 ). As part of this review, we will summarize the available literature examining the practical and ethical changes in conducting mental health readiness assessments and writing the associated letters.

While the WPATH guidelines specify eligibility criteria for GAC and a general guide for what information to include in a letter of readiness, there are no widely agreed upon standardized letter templates or semi-structured interviews, leading to a variety of practices in evaluation and letter writing for GAC ( 2 ). To our knowledge, this is the first scoping review to summarize the available research to date regarding the evolution of the mental health evaluation and process of writing letters of readiness for GAS. By summarizing trends in these evaluations over time, we aim to identify best practices and help further guide mental health professionals working in this field.

The review authors conducted a comprehensive search of the literature in collaboration with a research librarian (ABW) according to PRISMA guidelines. The search was comprised of database-specific controlled vocabulary and keyword terms for (1) mental health and (2) TGD-related surgeries. Searches were conducted on December 2, 2020 in MEDLINE (PubMed), the Cochrane Library Databases (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOhost), Scopus (Elsevier), and Dissertations and Theses Global (ProQuest). All databases were searched from inception to present without the use of limits or filters. In total, 8,197 results underwent multi-pass deduplication in a citation management system (EndNote), and 4,411 unique entries were uploaded to an online screening software (Rayyan) for title/abstract screening by two independent reviewers. In total, 303 articles were included for full text screening ( Figure 1 ), however, 69 of those articles were excluded as they were unable to be obtained online or through interlibrary loan. Both review authors conducted a full text screen of the remaining 234 articles. Articles were included in the final review if they specified criteria used for mental health screening/evaluation and/or letter writing for GAS, focused on TGD adults, were written in English, and were peer-reviewed publications. Any discrepancies were discussed between the two review authors TA and KK and a consensus was reached. A total of 86 articles met full inclusion criteria. Full documentation of all searches can be found in the Supplementary material .

PRISMA flow diagram demonstrating article review process.

In total, 86 articles were included for review. Eleven articles were focused on ethical considerations while the remaining 75 articles focused on the mental health evaluation and process of writing letters of readiness for GAS. Version 8 of the SOC was published in September of 2022 during the review process of this manuscript and is also included as a reference and point of discussion.

Prior to the publication of the standards of care

Fourteen articles were identified in the literature search as published prior to the development of the WPATH SOC version 1 in 1979. Prominent themes included classification, categorization, and diagnosis of TS. Few publications described the components of a mental health evaluation, and inclusion and exclusion criteria, for GAS. Many publications focused exclusively on transgender females, with a paucity of literature examining the experiences of transgender males during this timeframe.

Authors emphasized accurate diagnosis of TS, highlighting elements of the psychosocial history including early life cross-dressing, preference for play with the opposite gender toys and friends, and social estrangement around puberty ( 3 ). One author proposed the term gender dysphoria syndrome, which included the following criteria: a sense of inappropriateness in one’s anatomically congruent sex role, that role reversal would lead to improvement in discomfort, homoerotic interest and heterosexual inhibition, an active desire for surgical intervention, and the patient taking on an active role in exploring their interest in sex reassignment ( 4 ). Many authors attempted to differentiate between the “true transsexual” and other diagnoses, including idiopathic TS; idiopathic, essential, or obligatory homosexuality; neuroticism; TV; schizophrenia; and intersex individuals ( 5 , 6 ).

Money argued that the selection criteria for patients requesting GAS include a psychiatric evaluation to obtain collateral information to confirm the accuracy of the interview, work with the family to foster support of the individual, and proper management of any psychiatric comorbidities ( 5 ). Authors began to assemble a list of possible exclusion criteria for receiving GAS such as psychosis, unstable mental health, ambivalence, and secondary gain (e.g., getting out of the military), lack of triggering major life events or crises, lack of sufficient distress in therapy, presence of marital bonds (given the illegality of same-sex marriage during this period), and if natal genitals were used for pleasure ( 3 – 5 , 7 – 13 ).

Others focused the role of the psychiatric evaluation on the social lives and roles of the patient. They believed the evaluation should include exploring the patient’s motivation for change for at least 6–12 months ( 8 ), facilitating realistic expectations of treatment, managing family issues, providing support during social transition and post-operatively ( 13 ), and encouraging GAH and the “real-life test” (RLT). The RLT is a period in which a person must fully live in their affirmed gender identity, “testing” if it is right for them. In 1970, Green recommended that a primary goal of treatment was that, “the male patient must be able to pass in society as a socially acceptable woman in appearance and to conduct the normal affairs of the day without arousing undue suspicion” ( 14 ). Benjamin also noted concern that “too masculine” features may be a contraindication to surgery so as to not make an “acceptable woman” ( 7 ). Some publications recommended at least 1–2 years of a RLT ( 3 , 7 , 11 , 15 ), while others recommended at least 5 years of RLT prior to considering GAS ( 12 ). Emphasis was placed on verifying the accuracy of reported information from family or friends to ensure “authentic” motivation for GAS and rule out ambivalence or secondary gain (e.g., getting out of the military) ( 10 ).

Ell recommended evaluation to ensure the patient has “adequate intelligence” to understand realistic expectations of surgery and attempted to highlight the patient’s autonomy in the decision to undergo GAS. He wrote, “That is your decision [to undergo surgery]. It’s up to you to prove that you are a suitable candidate for surgery. It’s not for me to offer it to you. If you decide to go ahead with your plans to pass in the opposite gender role, you do it on your own responsibility” ( 8 ). Notably, many authors conceptualized gender transition along a binary, with individuals transitioning from one end to the other.

In these earliest publications, one can start to see the beginning framework of modern-day requirements for accessing GAS, including ensuring an accurate diagnosis of gender incongruence; ruling out other possible causes of presentation such as psychosis; ensuring general mental stability; making sure that the patient has undergone at least some time of living in their affirmed gender; and that they are able to understand the consequences of the procedure.

Standards of care version 1 and 2

Changes to the standards of care.

The first two versions of the WPATH SOC were written in 1979 and 1980, respectively and are substantially similar to one another. SOC version three was the first to be published in an academic journal in 1985 and changes from the first two versions were documented within this publication. The first two versions required that all recommendations for GAC be completed by licensed psychologists or psychiatrists. The first version recommended that patients requesting GAH and non-genital GAS, spend 3 and 6 months, respectively, living full time in their affirmed gender. These recommendations were rescinded in subsequent versions ( 16 ). Figure 2 reviews changes to the recommendations for GAC within the WPATH SOC over time.

Changes to the World Professional Association for Transgender Health (WPATH) standards of care around gender affirming medical and surgical treatments over time.

Results review

Five articles published between 1979 and 1980 were included in this review. Again, emphasis was placed on proper diagnosis, classification and consistency of gender identity over time ( 17 , 18 ).

Wise and Meyer explored the concept of a continuum between TV and TS, describing that those who experienced gender dysphoria often requested GAS, displayed evidence of strong cross-dressing desires with arousal, history of cross-gender roles, and absence of manic-depressive or psychotic illnesses ( 19 ). Requirements for GAS at the Johns Hopkins Gender Clinic included at least 2 years of cross-dressing, working in the opposite gender role, and undergoing treatment with GAH and psychotherapy ( 19 ). Bernstein identified factors correlated with negative GAS outcomes including presence of psychosis, drug abuse, frequent suicide attempts, criminality, unstable relationships, and low intelligence level ( 18 ). Lothstein stressed the importance of correct diagnosis, “since life stressors may lead some transvestites to clinically present as transsexuals desiring SRS” ( 20 ). Levine reviewed the diagnostic process employed by Case Western Reserve University Gender Identity Clinic which involved initial interview by a social worker to collect psychometric testing, followed by two independent psychiatric interviews to obtain the developmental gender history, understand treatment goals, and evaluate for underlying co-morbid mental health diagnoses, with a final multidisciplinary conference to integrate the various evaluations and develop a treatment plan ( 21 ).

Standards of care version 3

Version 3 broadened the definition of the clinician thereby broadening the scope of providers who could write recommendation letters for GAC. Whereas prior SOC required letters from licensed psychologists or psychiatrists, version 3 allowed initial evaluations from providers with at least a Master’s degree in behavioral science, and when required, a second evaluation from any licensed provider with at least a doctoral degree. Version 3 recommended that all evaluators demonstrate competence in “gender identity matters” and must know the patient, “in a psychotherapeutic relationship,” for at least 6 months ( 16 ). Version 3 relied on the definition of TS in DSM-III, which specified the sense of discomfort with one’s anatomic sex be “continuous (not limited to a period of stress) for at least 2 years” and be independently verified by a source other than the patient through collateral or through a longitudinal relationship with the mental health provider ( 16 ). Recommendation of GAS specifically required at least 6–12 months of RLT, for non-genital and genital GAS, respectively ( 16 ).”

Nine articles were published during the timeframe that the SOC version 3 were active (1981–1990). Themes in these publications included increasing focus on selection criteria for GAS and emphasis on the RLT, which was used to ensure proper diagnosis of gender dysphoria. Recommendations for the duration of the RLT ranged anywhere between 1 and 3 years ( 22 , 23 ).

Proposed components of the mental health evaluation for GAS included a detailed assessment of the duration, intensity, and stability of the gender dysphoria, identification of underlying psychiatric diagnoses and suicidal ideation, a mental status examination to rule out psychosis, and an assessment of intelligence (e.g., IQ) to comment on the individual’s “capacity and competence” to consent to GAC. The Minnesota Multiphasic Personality Inventory (MMPI), Weschler Adult Intelligence Scale (WAIS), and Lindgren-Pauly Body Image Scale were also used during assessments ( 24 ).

Authors developed more specific inclusion and exclusion criteria for undergoing GAS with inclusion criteria including age 21 or older, not legally married, no pending litigation, evidence of gender dysphoria, completion of 1 year of psychotherapy, between 1 and 2 years RLT with ability to “pass convincingly” and “perform successfully” in the opposite gender role, at least 6 months on GAH (if medically tolerable), reasonably stable mental health (including absence of psychosis, depression, alcoholism and intellectual disability), good financial standing with psychotherapy fees ( 25 ), and a prediction that GAS would improve personal and social functioning ( 26 – 29 ). A 1987 survey of European psychiatrists identified their most common requirements as completion of a RLT of 1–2 years, psychiatric observation, mental stability, no psychosis, and 1 year of GAH ( 27 ).

Standards of care version 4

World Professional Association for Transgender Health SOC version four was published in 1990. Between version three and version four, DSM-III-R was published in 1987. Version four relied on the DSM-III-R diagnostic criteria for TS as opposed to the DSM-III criteria in version three. The DSM-III-R criteria for TS included a “persistent discomfort and sense of inappropriateness about one’s assigned sex,” “persistent preoccupation for at least 2 years with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex,” and that the individual had reached puberty ( 30 ). Notable changes from the DSM-III criteria include specifying a time duration for the discomfort (2 years) and designating that individuals must have reached puberty.

Six articles were published between 1990 and 1998 while version four was active. Earlier trends continued including emphasizing proper diagnosis of gender dysphoria ( 31 , 32 ), however, a new trend emerged toward implementing more comprehensive evaluations, with an emphasis on decision making, a key element of informed consent.

Bockting and Coleman, in a move representative of other publications of this era, advocated for a more comprehensive approach to the mental health evaluation and treatment of gender dysphoria. Their treatment model was comprised of five main components: a mental health assessment consisting of psychological testing and clinical interviews with the individual, couple, and/or family; a physical examination; management of comorbid disorders with pharmacotherapy and/or psychotherapy; facilitation of identity formation and sexual identity management through individual and group therapy; and aftercare consisting of individual, couple, and/or family therapy with the option of a gender identity consolidation support group. Psychoeducation was a main thread throughout the treatment model and a variety of treatment “subtasks” such as understanding decision making, sexual functioning and sexual identity exploration, social support, and family of origin intimacy were identified as important. The authors advocated for “a clear separation of gender identity, social sex role, and sexual orientation which allows a wide spectrum of sexual identities and prevents limiting access to GAS to those who conform to a heterosexist paradigm of mental health” ( 33 ).

This process can be compared with the Italian SOC for GAS which recommend a multidisciplinary assessment consisting of a psychosocial evaluation and informed consent discussion around treatment options, procedures, and risks. Requirements included 6 months of psychotherapy prior to initiating GAH, 1 year of a RLT prior to GAS, and provision of a court order approving GAS, which could not be granted any sooner than 2 years after starting the process of gender transition. Follow-up was recommended at 6, 12, and 24 months post-GAS to ensure psychosocial adjustment to the affirmed gender role ( 34 ).

Other authors continued to refine inclusion and exclusion criteria for GAS by surveying the actual practices of health centers. Inclusion criteria included those who had life-long cross gender identification with inability to live in their sex assigned at birth; a 1–2 years RLT (a nearly universal requirement in the survey); and ability to pass “effortlessly and convincingly in society”; completed 1 year of GAH; maintained a stable job; were unmarried or divorced; demonstrated good coping skills and social-emotional stability; had a good support system; and were able to maintain a relationship with a psychotherapist. Exclusion criteria included age under 21 years old, recent death of a parent ( 35 ), unstable gender identity, unstable psychosocial circumstances, unstable psychiatric illness (such as schizophrenia, suicide attempts, substance abuse, intellectual disability, organic brain disorder, AIDS), incompatible marital status, criminal history/activity or physical/medical disability ( 36 ).

The survey indicated some programs were more lenient around considering individuals with bipolar affective disorder, the ability to pass successfully, and issues around family support. Only three clinics used sexual orientation as a factor in decision for GAS, marking a significant change in the literature from prior decades. Overall, the authors found that 74% of the clinics surveyed did not adhere to WPATH SOC, instead adopting more conservative policies ( 36 ).

Standards of care version 5

Published in 1998, version five defined the responsibilities of the mental health professional which included diagnosing the gender disorder, diagnosing and treating co-morbid psychiatric conditions, counseling around GAC, providing psychotherapy, evaluating eligibility and readiness criteria for GAC, and collaborating with medical and surgical colleagues by writing letters of recommendation for GAC ( Figure 3 ). Eligibility and readiness criteria were more explicitly described in this version to refer to the specific objective and subjective criteria, respectively, that the patient must meet before proceeding to the next step of their gender transition. The seven elements to include in a letter of readiness were more explicitly listed within this version as well including: the patient’s identifying characteristics, gender, sexual orientation, any other psychological diagnoses, duration and nature of the treatment with the letter writer, whether the author is part of a gender team, whether eligibility criteria have been met, the patient’s ability to follow the SOC and an offer of collaboration. Version five removes the requirement that patients undertake psychotherapy to be eligible for GAC ( 37 ).

Changes to the ten tasks of the mental health provider within the World Professional Association for Transgender Health (WPATH) standards of care over time.

Five articles were published between 1998 and 2001 while version five was active. Two of these articles were summaries of the SOC ( 37 , 38 ). Themes in these publications included continued attempts to develop comprehensive treatment models for GAS.

Ma reviewed the role of the social worker in a multidisciplinary gender clinic in Hong Kong. Psychosocial assessment for GAS included evaluation of performance in affirmed social roles, adaptation to the affirmed gender role during the 1-year RLT and understanding the patient’s identified gender role and the response to the new gender role culturally and interpersonally within the individual’s support network and family unit. She noted five contraindications to GAS: a history of psychosis, sociopathy, severe depression, organic brain dysfunction or “defective intelligence,” success in parental or marital roles, “successful functioning in heterosexual intercourse,” ability to function in the pretransition gender role, and homosexual or TV history with genital pleasure. She proposed a social work practice model for patients who apply for GAS with categorization of TGD individuals into “better-adjusted” and “poorly-adjusted” with different intervention goals and methods for each. For those who were “better-adjusted,” treatment focused on psychoeducation, building coping tools, and mobilization into a peer counselor role, while treatment goals for those who were “poorly-adjusted” focused on building support and resources ( 39 ).

Damodaran and Kennedy reviewed the assessment and treatment model used by the Monash gender dysphoria clinic in Melbourne, Australia for patients requesting GAS. All referrals for GAS were assessed independently by two psychiatrists to determine proper diagnosis of gender dysphoria, followed by endocrinology and psychology consultation to develop a comprehensive treatment plan. Requirements included RLT of minimum 18 months and GAH ( 40 ).

Miach reviewed the utility of using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), a revision of the MMPI which was standardized using a more heterogeneous population, in a gender clinic to assess stability of psychopathology prior to GAS, which was only performed on patients aged 21–55 years old. The authors concluded that while the TGD group had a significantly lower level of psychopathology than the control group, they believed that the MMPI-2 was a useful test in assessing readiness for GAC ( 41 ).

Standards of care version 6

Published in 2001, version six of the WPATH SOC did not include significant changes to the 10 tasks of the mental health professional ( Figure 3 ) or in the general recommendations for content of the letters of readiness. An important change in the eligibility criteria for GAH allowed providers to prescribe hormones even if patients had not undergone RLT or psychotherapy if it was for harm reduction purposes (i.e., to prevent patient from buying black market hormones). A notable change in version six separated the eligibility and readiness criteria for top (breast augmentation or mastectomy) and bottom (any gender-affirming surgical alteration of genitalia or reproductive organs) surgery allowing some patients, particularly individuals assigned female at birth (AFAB), to receive a mastectomy without having been on GAH or completing a 12 month RLT ( 42 , 43 ).

Thirteen articles were published between 2001 and 2012. One is a systematic review of evidence for factors that are associated with regret and suicide, and predictive factors of a good psychological and social functioning outcome after GAC. De Cuypere and Vercruysse note that less than one percent of patients regret having GAS or commit suicide, making detection of negative predictive factors in a study nearly impossible. They identified a wide array of positive predictive factors including age at time of request, sex of partner, premorbid social or psychiatric functioning, adequacy of social support system, level of satisfaction with secondary sexual characteristics, and surgical outcomes. Many of these predictive factors were later disproved. They also noted that there were not enough studies to determine whether following the WPATH guidelines was a positive predictive factor. In the end they noted that the evidence for all established evaluation regimens (i.e., RLT, age cut-off, psychotherapy, etc.) was at best indeterminate. They recommended that changes to WPATH criteria should redirect focus from gender identity to psychopathology, differential diagnosis, and psychotherapy for severe personality disorders ( 44 ).

The literature at this time supports two opposing approaches to requests for GAC, those advocating for a set of strictly enforced eligibility and readiness criteria associated with very thorough evaluations and those who advocate for a more flexible approach. Common approaches to the evaluation for GAC include: taking a detailed social history including current relationships, support systems, income, and social functioning; a sexual development history meant to understand when and how the patient began to identify as TGD and how their transition has affected their life; an evaluation of their coping skills, “psychic functions” and general mental well-being; and a focus on assessing the “correct diagnosis” of gender identity disorder ( 44 – 56 ). The use of a multidisciplinary team was also commonly recommended ( 44 , 47 , 48 , 51 , 54 – 56 ).

Those that advocated for a stricter interpretation of the eligibility and readiness criteria emphasized the importance of the RLT ( 45 , 49 , 51 , 53 , 55 , 56 ). One clinic in the UK required a RLT lasting 2 years prior to starting GAH, twice as long as recommended by the SOC ( 49 ). The prevailing view continued to approach gender as a binary phenomenon, rather than as a spectrum of experiences. As a result, treatment recommendations emphasized helping the patient to “pass” in their chosen gender role and did not endorse patients receiving less than the full spectrum of treatment to transition fully from one sex to the other. Several authors indicated that they required some amount of psychotherapy before recommending GAC ( 46 , 47 , 51 , 52 , 55 , 56 ). One author described requirements in Turkey, which unlike the US has the requirements enshrined in law and defines an important role for the courts in granting permission for GAC ( 51 ). In general, these authors supported the gatekeeping role of the mental health provider as a mechanism to prevent cases of regret.

Among groups supporting a flexible interpretation of the SOC, there was a much stronger emphasis on the supportive role of the mental health provider in the gender transition process ( 44 – 46 , 48 , 52 , 53 ). This role included creating a supportive environment for the patient, asking and using the correct pronouns, and helping to guide them through what may be a difficult transition both socially and physically. They emphasized the importance of the psychosocial evaluation including the patient’s connections to others in the TGD community, their social functioning, substance use, and psychiatric history/psychological functioning. While informed consent was mentioned as part of the evaluation, the process was not thoroughly explored and largely focused on patients’ awareness that GAS is an irreversible procedure which removes healthy tissue ( 53 ). One author suggested that a “consumer handbook outlining such rights and responsibilities” related to GAS be made available, but they made no further comment on the informed consent process ( 44 ). There was no further guidance as to the contents of letters of readiness for GAC.

The lack of emphasis on informed consent by both groups of authors mirrors the discussion of informed consent within the SOC, which up through version six, had a relatively narrow definition and role specifically related to risks and benefits of surgery. As far back as version one, the SOC states “hormonal and surgical sex reassignment are procedures which must be requested by, and performed only with the agreement of, the patient having informed consent…[these procedures] may be conducted or administered only after the patient applicant has received full and complete explanations, preferably in writing, in words understood by the patient applicant, of all risks inherent in the requested procedures ( 16 ). “This reflects the dominant concerns of surgeons at the time that they were removing or damaging healthy tissue, which was unethical, and as such wanted to make sure that patients understood the irreversibility of the procedures. It was not until version 7 that there is a change in the discussion of informed consent.

Standards of care version 7

Standards of care version seven was published in 2013. Publication of version seven coincided with the publication of DSM-5, in which the diagnosis required to receive GAC shifted from Gender Identity Disorder to Gender Dysphoria, in an effort to de-pathologize TGD patients. Version seven highlights that these are guidelines meant to be flexible to account for different practices in different places. Compared to version six, a significantly expanded section on the “Tasks of the Mental Health Provider” was added, offering some instructions on what to include in the assessment of the patient for GAS. For the first time the SOC expand on what it means to obtain informed consent and describe a process where the mental health provider is expected to guide a conversation around gender identity and how different treatments and procedures might affect TGD individuals psychologically, socially, and physically. Other recommendations include “at a minimum, assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender non-conformity on mental health, and the availability of support from family, friends, and peers.” There is also a change to the recommended content of the letters: switching from “The initial and evolving gender, sexual, and other psychiatric diagnoses” to “Results of the client’s psychosocial assessment, including any diagnoses”, indicating a shift in the focus away from diagnosis toward the psychosocial assessment. Version 7 also adds two new tasks for the mental health provider including “Educate and advocate on behalf of clients within their community (schools, workplaces, other organizations) and assist clients with making changes in identity documents” and “Provide information and referral for peer support”( 2 ).

There were also significant changes to eligibility criteria for GAC. For GAH, version seven eliminates entirely the requirement for a RLT and psychotherapy and adds requirements for “persistent well documented gender dysphoria” and “reasonably well controlled” medical or mental health concerns. Notably, the SOC do not define the meaning of “reasonably well controlled,” leaving providers to interpret this on their own. Version seven delineates separate requirements for top and bottom surgeries. The criteria for both feminizing and masculinizing top surgeries are identical to each other and identical to those laid out for GAH. Version seven explicitly states that GAH is not required prior to top surgery, although GAH is still recommended prior to gender-affirming breast augmentation. Criteria for bottom surgery are more explicitly defined, namely internal (i.e., hysterectomy, orchiectomy) vs. external (i.e., metoidioplasty, phalloplasty, and vaginoplasty). For internal surgeries, criteria are the same as for top surgery with the addition of a required 12 months of GAH. For external surgeries the criteria are the same as for internal, with the addition of required 12 months of living in the patient’s affirmed gender identity ( 2 , 42 ).

Twenty-three articles were published while version 7 of the SOC have been active. Themes include identifying the role of psychometric testing in GAC evaluations, expanding the discussion around informed consent for GAC, and revising the requirements for letter writers.

A systematic review evaluated the accuracy of psychometric tests in those requesting GAC, identifying only two published manuscripts that met their inclusion criteria, both of which were of poor quality; this led them to question the utility of psychometric tests in in TGD patients ( 57 ). Keo-Meir and Fitzgerald provided a detailed narrative review of psychometric and neurocognitive exams in the TGD population and concluded that psychometric testing should not be done unless there is a question about the capacity of the patient to provide informed consent ( 58 ). The only other manuscripts that include a mention of psychological testing describe processes in Iran and China, both of which require extensive psychological testing prior to approval for GAC ( 59 , 60 ). These two manuscripts, in addition to an ethnographic study of the evaluation process in Turkey ( 61 ), are also the only ones that indicate a requirement for psychotherapy prior to approval for treatment. The three international manuscripts described above plus three manuscripts from the US ( 62 – 64 ) are the only ones to include consideration of a RLT, with authors outside the US preferring a long RLT and US authors considering RLT as part of the informed consent process for GAS, and not required at all prior to the initiation of GAH.

Many authors describe the process of informed consent for GAC ( 1 , 58 , 60 , 62 – 76 ). In China, a signature indicating informed consent from the patient’s family is required in addition to that of the patient ( 60 ). Many authors emphasize evaluating for and addressing social determinants of health including housing status, income, transportation, trauma history, etc. ( 1 , 58 , 60 , 67 , 69 – 71 , 75 – 77 ). Deutsch advocated for the psychosocial evaluation being the most important aspect of the evaluation and suggests that one of the letters required for bottom surgery be replaced by a functional assessment (i.e., ADLs/iADLs), which could be repeated as needed or removed entirely for high functioning patients ( 69 ).

Practice patterns and opinions on who should write letters of readiness and how many letters should be required vary widely. Many letters that surgeons receive are cursory, and short and non-personal letters correlate with poor surgical outcomes ( 1 ). Several authors advocate for eliminating the second letter entirely, for at least some procedures, as it is a barrier to care ( 68 , 69 , 74 ). Some support removing the requirement that both letter writers be therapists or psychiatrists, and even suggesting the second letter be written by a urologist ( 72 ) or a social worker who has performed a detailed social assessment ( 69 , 75 ). The evaluation in Turkey requires a report written by an extensive multidisciplinary team and submitted to a court for approval ( 61 ). Surveys of providers indicate that the SOC are not uniformly implemented leading to huge disparities based on the providers knowledge level and personal beliefs ( 77 , 78 ). Additional recommendations include that providers spend significant time discussing the SOC and diagnosis of gender dysphoria with the patients prior to providing a letter to prepare them for the stigma such a diagnosis may confer ( 65 , 66 ), and dropping gender dysphoria entirely in favor the ICD-11 diagnosis of gender incongruence, as it may be less stigmatizing ( 71 ).

The Mount Sinai Gender Clinic describes an integrated multidisciplinary model where a patient will see a primary care doctor, endocrinologist, social worker, psychiatrist, and obtain any necessary lab work in a single visit, significantly reducing barriers to care. The criteria in this model focus on informed consent, the social determinants of health, being physically ready for surgery, and putting measurable goals on psychiatric stability, while deemphasizing the gender dysphoria diagnosis. Their study showed that people who received their evaluation over a 2-year period were more likely to meet their in-house criteria than they were to meet criteria as set forth in WPATH SOC. The Mount Sinai criteria allowed for significantly decreased barriers to care, allowing more people to progress through desired GAC in a timely fashion ( 75 ).

Standards of care version 8

Standards of care version 8, published in September 2022, includes major updates to the guidelines around GAS. This version explicitly highlights the importance of informed decision making, patient autonomy, and harm reduction models of care, as well as emphasizing the flexibility of the guidelines which the authors note can be modified by the healthcare provider in consultation with the TGD individual.

Version 8 lays out the roles of the assessor which are to identify the presence of gender incongruence and any co-existing mental health concerns, provide information on GAC, support the TGD individual in their decision-making, and to assess for capacity to consent to GAC. The authors emphasize the collaborative nature of this decision-making process between the assessor and the TGD individual, as well as recommending TGD care occur in a multidisciplinary team model when possible.

Version 8 recommends that providers who assess TGD individuals for GAC hold at least a Master’s level degree and have sufficient knowledge in diagnosing gender incongruence and distinguishing it from other diagnoses which may present similarly. These changes allow for non-mental health providers to be the main assessors for GAC.

Version 8 recommends reducing the number of evaluations prior to GAS to a single evaluation in an effort to reduce barriers to care for the TGD population. Notably, the authors have removed the recommendations around content of the letter of readiness for GAC. The guidelines note that the complexity of the assessment process may differ from patient to patient, based on the type of GAC requested and the specific characteristics of the patient. Version eight directly states that psychometric testing and psychotherapy are not requirements to pursue GAC. While evaluations should continue to identify co-existing mental health diagnoses, version 8 highlights that the presence of a mental health diagnosis should not prevent access to GAC unless the mental health symptoms directly interfere with capacity to provide informed consent for treatment or interfere with receiving treatment. Version 8 recommends that perioperative matters, such as travel requirements, presence of stable, safe housing, hygiene/healthy living, any activity restrictions, and aftercare optimization, be discussed by the surgeon prior to GAS. In terms of eligibility criteria, the authors recommend a reduced duration of GAH from 12 months (from version 7) to 6 months (in version 8) prior to pursuing GAS involving reproductive organs ( 79 ).

Ethical discussions

A total of eleven articles explored ethical considerations of conducting mental health evaluations and writing letters of readiness for GAS, including a comparison of the ethical principles prioritized within the “gatekeeping” model vs. the informed consent model for GAC and the differential treatment of TGD individuals compared to cisgender individuals seeking similar surgical procedures.

Many authors compare the informed consent model of care for TGD individuals to the WPATH SOC model. In the informed consent model, the role of the health practitioner is to provide TGD patients with information about risks, side effects, benefits, and possible consequences of undergoing GAC, and to obtain informed consent from the patient ( 80 ). Cavanaugh et al. argue that the informed consent model is more patient-centered and elevates the ethical principle of autonomy above non-maleficence, the principle often prioritized in the “gatekeeping” model ( 81 ). They write, “Through a discussion of risks and benefits of possible treatment options with the patient…clinicians work to assist patients in making decisions. This approach recognizes that patients are the only ones who are best positioned, in the context of their lived experience, to assess and judge beneficence (i.e., the potential improvement in their welfare that might be achieved), and it also affords prescribing clinicians a better and fuller sense of how a particular patient balances principles of non-maleficence and beneficence.” Authors note that mental health providers can be particularly helpful in situations where an individual desires additional mental health treatment, which some argue should remain optional, or when an individual’s capacity is in question ( 81 ). Additional ethical considerations include balancing the respect for the dignity of persons, responsible caring, integrity in relationships, and responsibility to society ( 82 ). Other authors argue for a more systematic approach to ethical issues, including consulting the literature and/or experts in the field of TGD mental health for support in making decisions around GAC ( 74 ).

Hale criticizes the WPATH SOC noting that these guidelines create a barrier between patient and mental health provider in establishing trust and a therapeutic relationship, overly pathologize TGD individuals, and unnecessarily impose financial costs to the TGD individual. As a “gatekeeper,” the mental health provider is placed in the position of either granting or denying GAC and must weigh the competing ethical principles of beneficence, non-maleficence, and autonomy. He argues that mental health providers are not surrogate decision makers and that framing requests for GAS as a “phenomenon of incapacity” is “reflective of the overall incapacitating effects of society at large toward the TGD community” ( 83 ). This reflects the broader approach to determining capacity utilized in other medical contexts, namely that patients have capacity until proven otherwise ( 84 ). Additionally, due to the gatekeeping dynamic between patient and clinician, many TGD patients may not mention concerns or fears surrounding GAS out of concern they will be denied services, thereby limiting the quality and utility of the informed consent discussion. Ashley proposes changes to the informed consent model, specifically that the informed consent process should include not only information about whether to go through with a procedure, but how to go through the procedure including relevant information about timeline, side effects, need for perioperative support, and treatment plan ( 85 ). Gruenweld argues for a bottom-up, TGD-led provision of GAC instead of focusing solely on alleviating gender dysphoria through a top-down, medical expert approach via such systems like the WPATH SOC ( 86 ).

MacKinnon et al. conducted an institutional ethnographic study of both TGD individuals undergoing mental health evaluations for GAC and mental health providers to better understand the process of conducting such evaluations ( 87 ). They found that providers cited three concerns with the evaluation: determining the authenticity of an individual’s TGD identity, determining if the individual has the capacity to consent to treatment, and determining the readiness of the individual to undergo treatment. TGD individuals cited concerns around presenting enough distress to be diagnosed with gender dysphoria (a SOC requirement) versus too much distress, and risk being diagnosed with an uncontrolled mental health condition therefore being ineligible for GAC. The authors conclude, “although they are designed to optimize and universalize care… psychosocial readiness assessments actually create a medically risky and arguably unethical situation in which trans people experiencing mental health issues have to decide what is more important – transitioning at the potential expense of care for their mental health or disclosing significant mental health issues at the expense of being rendered not ready to transition (which in turn may produce or exacerbate mental distress)” ( 87 ).

With regards to writing letters of readiness for GAS, authors comment on the differential treatment of TGD compared to cisgender individuals. Bouman argues that requiring two letters for gender-affirming orchiectomy or hysterectomy is unethical given that orchiectomy and hysterectomy for chronic scrotal pain and dysfunctional uterine bleeding, respectively, do not require any mental health evaluation. Requiring a second letter may cause delays in treatment, increase financial costs, and may be invasive to the patient who must undergo two detailed evaluations, while allowing for diffusion of responsibility for the mental health provider ( 88 ).

Changing standards

Starting in the 1950’s with the first successful gender affirming procedure in the US on Christine Jorgenson, TGD people in the US started seeking surgical treatment of what was then called TS. The medical community’s understanding of TGD people, their mental health, and the role of the mental health provider in their medical and surgical transition has progressed and evolved since this time. Prior to the first iteration of what would later be known as WPATH’s SOC, patients were mostly evaluated within a system that viewed gender and sexual minorities as deviants and thereby largely limited access to GAC. We can also see this reflected in the changes to DSM and ICD diagnostic criteria between 1980 and today which demonstrates a trend from pathologizing identity and conflating sexual and gender identity toward pathologizing the distress experienced due to the discordant identity, and finally removing the relevant diagnosis from the chapter of Mental and Behavioral Disorders altogether in the ICD and instead into a new chapter titled “conditions related to sexual health ( 89 ).” These changes have clearly yielded positive benefits for TGD individuals by reducing stigma and improving access to care, but significant problems remain. Requiring TGD people to have a diagnosis at all to obtain care, no matter the terminology used, is pathologizing. The practice of requiring a diagnosis continues to put mental health and other medical providers in the position of gatekeeping, continuing the vestigial historical focus on “confirming” a person’s gender identity, rather than trusting that TGD people understand their identities better than providers do. Version 8 of the SOC put a much heavier emphasis on shared decision making and informed consent, but continue to maintain the requirement of a diagnosis ( 79 ). Many insurance companies and other health care payers require the diagnosis to justify paying for GAC, but providers should continue to advocate for removing such labels as a gatekeeping mechanism for GAC.

With each version of the SOC, guidelines for GAC become more specific, with more explanation of the reasoning behind each recommendation; more flexible requirements, a broadening of the definition of mental health provider, and elimination of the requirement that at least one letter be written by a doctoral level provider. There has been a notable shift in the conceptualization of gender identity, away from a strict gender binary, with individuals transitioning fully from one end to the other, to gender identity and transition as a spectrum of experiences. Over time the SOC became more flexible by removing requirements for psychotherapy, narrowing requirement for the RLT to only those pursuing bottom surgery, eliminating requirements for a mental health evaluation prior to initiating GAH, and eliminating requirements for GAH prior to top surgery. Version 8 of the SOC was even more explicit about removing requirements for psychotherapy and psychometric testing prior to receiving GAC ( 79 ).

Despite these positive changes, those wishing to access GAC still face significant challenges. Access to providers knowledgeable about GAC remains limited, especially in more rural areas, therefore requiring evaluations and letters of readiness for GAC continues to significantly limit access to treatment. By requiring letters of readiness for GAC, adult TGD individuals are not afforded the same level of autonomy present in almost any other medical context, where capacity to provide informed consent is automatically established ( 84 ). The WPATH SOC continue to perpetuate differential treatment of TGD individuals by requiring extensive, and often invasive, evaluations for procedures that their cisgender peers are able to access without such evaluations ( 88 ). The WPATH guidelines apply a one-size-fits-all approach to an extremely heterogeneous community who have varying levels of needs based on a variety of factors including but not limited to age, socioeconomic status, race, natal sex, and geographic location ( 90 ). It should be noted, however, that the version 8 of the SOC does acknowledge that different patients may require evaluations of varying complexity based on the procedure they are requesting as well as a variety of psychosocial factors, although it remains vague about exactly what those different evaluations should entail ( 79 ). We propose that future work be directed toward three primary goals: conducting research to determine the utility of letters of readiness; to better understand factors that impact GAS outcomes; and to develop easily accessible and understandable guides to conducting readiness evaluations and writing letters. These aims will help to further our goals of advocating for this vastly underserved population by further removing barriers to life-saving GAC.

Changing ethics

Early iterations of the SOC were strict, placing the mental health provider within a gatekeeper role, tasked with distinguishing the “true transsexual” that would benefit from GAS from those who would not, which in effect elevated the ethical principal of non-maleficence above autonomy. This created a barrier to forming a therapeutic alliance between the patient and mental health provider as there was little motivation for patients to give any information outside of the expected gender narrative ( 50 , 65 ). Mistrust flowed both ways leading to longer and more involved evaluations then than what is required today, with many providers requiring patients to undergo extensive psychological testing and psychotherapy, provide extensive collateral, and undergo lengthy RLTs, with some focusing on a patient’s ability to “pass” within the desire gender role, before agreeing to write a letter ( 11 , 15 , 19 , 49 , 57 , 58 ).

As understanding around the experiences of TGD individuals has evolved over time, the emphasis has shifted from the reliance on non-maleficence toward elevating patient autonomy as the guiding principle of care. Evaluations within this informed consent model focus much more on the patient’s ability to understand the treatment, its aftercare, and its potential effect on their lives. Informed consent evaluations also shift focus toward other psychosocial factors that will contribute to successful surgical outcomes, for example, housing, transportation, a support system, and treatment of any underlying mental health symptoms. While there is still a lack of consistency in current evaluations and the SOC are enforced unevenly ( 77 ), the use of the informed consent model by some providers has reduced barriers for some patients. Many authors now agree that psychological or neuropsychological testing should not be used when evaluating for surgical readiness unless there is a concern about the patient’s ability to provide informed consent such as in the case of a neurocognitive or developmental disorder ( 58 ). Also important to note here is that while there is a general shift in the focus of the literature from that of gatekeeping toward one of informed consent, neither the informed consent model nor the WPATH SOC more broadly are evenly applied by providers, leading to continued barriers for many patients ( 77 , 78 ).

Within the literature, there is support for further reducing barriers to care by widening the definition of who can conduct evaluations, write letters, or facilitate the informed consent discussion for GAC. Recommending that the physician providing the GAC be the one to conduct the informed consent evaluation would bring GAC practices more in line with practices in place within the broader medical community. It is very rare for mental health providers to be the gatekeepers for medical or surgical procedures, except for transplant surgery, where mental health providers may have a clearer role given the prominence of substance use disorders and the very limited resource of organs. However, even within transplant psychiatry, a negative psychiatric evaluation would not necessarily preclude the patient from receiving the transplant, but instead may be used to guide a treatment plan to improve chances of a successful recovery post-operatively. We then should consider what it means to embrace patient autonomy as our guiding principle, especially with more than 40 years of evidence of the positive effects around GAC behind us. Future guidelines should focus on making sure that TGD individuals are good surgical candidates, not based on their gender identity, but instead on a more holistic understanding of the factors that lead to good and bad gender-affirming surgical outcomes, along the lines of those proposed by Mt. Sinai’s gender clinic for vaginoplasty ( 75 ). Additionally, the physicians providing the GAC should in most cases be the ones to obtain informed consent, while retaining the ability to request a mental health evaluation if specific concerns related to mental health arise. This would both allow mental health providers to adopt a supportive consultant role rather than that of gatekeeper, as well as provide more individualized rather than one-size-fits-all care to patients.

Version 8 of the SOC go a long way toward changing the ethical focus of evaluations toward one of shared decision making and informed consent by removing the requirement of a second letter and the requirement that the letter be written by a mental health provider. This will, in theory, lower barriers to care by allowing other providers (as long as they have at least a master’s degree) to write letters for surgery ( 79 ). In practice, however, this change is likely to only affect a small portion of the patient population. This is because, as noted in the section below in more detail, insurance companies already do not adhere closely to the SOC ( 91 ) and are unlikely to quickly adopt the new guidelines if at all. Further, it is possible that many surgeons will require that the letter of readiness be written by a mental health provider, especially if the patient has any previous mental health problems. While changes to SOC 8 are a step in the direction we propose in this manuscript, it is important to remember that the primary decision makers of who can access GAC in the US are insurance companies with surgeons, primary care providers, and mental health providers as secondary decision makers; this leaves patients with much less real-world autonomy than the SOC state they should have in the process. While insurance companies hold this effective decision-making power in all of US healthcare, it could be at least partially addressed by developing clear, evidence based guidelines for which patients might require a more in-depth evaluation in the first place. Screening out patients that have little or no mental health or social barriers to care would directly reduce those patients’ barriers to receiving GAC, while freeing up mental health and other providers to provide evaluation, resources, and support to those patients who will actually benefit from these services.

Letter writing

There are few published guides for writing letters of readiness for GAC. The WPATH SOC provide vague guidelines as to the information to include within the letter itself, which, in addition to a lack of consistency in implementation of the SOC, lead to a huge variety in current practices around letter writing and limit their usefulness to surgical providers ( 1 ). There is much debate within the literature about how many letters should be required and who should be able to write them. Guidelines from China, Turkey, and Iran recommend much stricter processes requiring input from a wider variety of specialists to comment on a patient’s readiness ( 59 – 61 ). Within the US, the few recent recommendations include having a frank discussion with patients about the gender dysphoria diagnosis and allowing them to have input into the content of the letter itself ( 65 , 66 , 70 , 71 , 75 ). The heterogeneity of current practices around letter writing demonstrates a reality in which many providers do not uniformly operate within the informed consent model, and do not even uniformly adhere to the SOC as written. This heterogeneity in practice by providers also extends to requirements by insurance companies in the US. The lack of clear guidelines about what should go into a letter, especially across different insurance providers, can lead to increased barriers to care due to insurance denials for incorrectly written letters. While direct data examining insurance denials for incorrectly written letters is not available, we can see this indirect effects in the fact that while 90% of insurance providers in the US provide coverage for GAC, only 5–10% of TGD patients had received bottom surgery even though about 50% of TGD patients have reported wanting it ( 91 ). Version 8 of the SOC reduce some of the letter writing requirements as discussed above, but they still do not give clear instructions on exactly how to write a letter of readiness or perform an evaluation ( 79 ). Given the lack of uniformity and limited benefit of such letters to surgical providers, these authors propose that future research be conducted into the need for letters of readiness for GAC, ways to ensure the content of such letters are evidence-based to improve outcomes of GAC, and improve education to providers by creating an easily accessible and free semi-structured interview with letter template.

Limitations

The reviewed articles included opinion manuscripts, published SOC, and proposed models for how to design and operate GAC clinics, however, this narrative review is limited by a lack of peer reviewed clinical trials that assess the evidence for the GAC practices described here. As a result, it is challenging to comment on the effectiveness of various interventions over time.

The WPATH SOC have evolved significantly over time with regards to their treatment of TGD individuals. Review of the literature shows a clear progression of practices from paternalistic gatekeeping toward increasing emphasis on patient autonomy and informed consent. Mental health evaluations, still required by SOC version eight are almost entirely unique as a requirement for GAS, apart from some bariatric and transplant surgeries. Individuals who wish to pursue GAC are required to get approval for treatments that their cisgender peers may pursue without such evaluations. While there may be some benefits from these evaluations in helping to optimize a patient socially, emotionally, and psychologically for GAC, the increased stigma and burden placed on patients by having a blanket requirement for such evaluations leads us to seriously question the readiness evaluation requirements in SOC version 8, despite a reduction in the requirements compared to previous SOC. This burden is made worse by limited access to providers knowledgeable and competent in conducting GAC evaluations, writing letters of readiness, and a lack of consistency in the application and interpretations of the SOC by both providers and insurance companies. Other barriers to care created by multiple letter requirements include the often-prohibitive cost of getting multiple evaluations and the delay in receiving their medical or surgical treatments due to extensive wait times to see a mental health provider. This barrier will in theory be ameliorated by updates to SOC in version 8, but multiple letters are likely to at least be required by insurance companies for some time. Overall, the shift from gate keeping to informed consent has been a net positive for patients by reducing barriers to care and improving patient autonomy, but the mental health evaluation is still an unnecessary barrier for many people. Further research is necessary to develop a standardized evaluation and letter template for providers to access, as well as further study into who can most benefit from an evaluation in the first place.

Data availability statement

Author contributions.

TA and KK contributed to the conception and design of the study under the guidance of RL and AJ, reviewed and analyzed the literature, and wrote the manuscript. AW organized the literature search and wrote the “Methods” section. RL and AJ assisted in review and revision of the completed manuscript. All authors approved of the submitted version.

Abbreviations

1 Gender affirming surgery has historically been referred to as sexual reassignment surgery (SRS).

2 Gender affirming care is an umbrella term referring to any medical care a TGD individual might pursue that affirms their gender identity, including primary care, mental health care, GAH or GAS.

3 The organization will be referred to as WPATH moving forward, even when referring to time periods before the name change.

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.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.1006024/full#supplementary-material

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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Frank Kitchen : I killed a lot of guys. They were worthless pieces of shit, but I killed them, and you're not supposed to kill people. So what happened to me? I guess maybe in the end... it was a lot better than what I deserved. But it takes a long time to work that out. In the meantime, you just want to get get even.

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Vatican Document Casts Gender Change and Fluidity as Threat to Human Dignity

The statement is likely to be embraced by conservatives and stir consternation among L.G.B.T.Q. advocates who fear it will be used as a cudgel against transgender people.

By Jason Horowitz and Elisabetta Povoledo

Reporting from Rome

The Vatican on Monday issued a new document approved by Pope Francis stating that the church believes that gender fluidity and transition surgery, as well as surrogacy, amount to affronts to human dignity.

The sex a person is assigned at birth, the document argued, was an “irrevocable gift” from God and “any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.” People who desire “a personal self-determination, as gender theory prescribes,” risk succumbing “to the age-old temptation to make oneself God.”

Regarding surrogacy, the document unequivocally stated the Roman Catholic Church’s opposition, whether the woman carrying a baby “is coerced into it or chooses to subject herself to it freely.” Surrogacy makes the child “a mere means subservient to the arbitrary gain or desire of others,” the Vatican said in the document, which also opposed in vitro fertilization.

The document was intended as a broad statement of the church’s view on human dignity, including the exploitation of the poor, migrants, women and vulnerable people. The Vatican acknowledged that it was touching on difficult issues, but said that in a time of great tumult, it was essential, and it hoped beneficial, for the church to restate its teachings on the centrality of human dignity.

Even if the church’s teachings on culture war issues that Francis has largely avoided are not necessarily new, their consolidation now was likely to be embraced by conservatives for their hard line against liberal ideas on gender and surrogacy.

The document, five years in the making, immediately generated deep consternation among advocates for L.G.B.T.Q. rights in the church, who fear it will be used against transgender people. That was so, they said, even as the document warned of “unjust discrimination” in countries where transgender people are imprisoned or face aggression, violence and sometimes death.

“The Vatican is again supporting and propagating ideas that lead to real physical harm to transgender, nonbinary and other L.G.B.T.Q.+ people,” said Francis DeBernardo, the executive director of New Ways Ministry, a Maryland-based group that advocates for gay Catholics, adding that the Vatican’s defense of human dignity excluded “the segment of the human population who are transgender, nonbinary or gender nonconforming.”

He said it presented an outdated theology based on physical appearance alone and was blind to “the growing reality that a person’s gender includes the psychological, social and spiritual aspects naturally present in their lives.”

The document, he said, showed a “stunning lack of awareness of the actual lives of transgender and nonbinary people.” Its authors ignored the transgender people who shared their experiences with the church, Mr. DeBernardo said, “cavalierly,” and incorrectly, dismissing them as a purely Western phenomenon.

Though the document is a clear setback for L.G.B.T.Q. people and their supporters, the Vatican took pains to strike a balance between protecting personal human dignity and clearly stating church teaching, a tightrope Francis has tried to walk in his more than 11 years as pope.

Francis has made it a hallmark of his papacy to meet with gay and transgender Catholics and has made it his mission to broadcast a message for a more open, and less judgmental, church. Just months ago, Francis upset more conservative corners of his church by explicitly allowing L.G.B.T.Q. Catholics to receive blessings from priests and by allowing transgender people to be baptized and act as godparents .

But he has refused to budge on the church rules and doctrine that many gay and transgender Catholics feel have alienated them, revealing the limits of his push for inclusivity.

“In terms of pastoral consequences,” Cardinal Víctor Manuel Fernández, who leads the Vatican’s office on doctrine, said in a news conference Monday, “the principle of welcoming all is clear in the words of Pope Francis.”

Francis, he said, has repeatedly said that “all, all, all” must be welcomed. “Even those who don’t agree with what the church teaches and who make different choices from those that the church says in its doctrine, must be welcomed,” he said, including “those who think differently on these themes of sexuality.”

But Francis’ words were one thing, and church doctrine another, Cardinal Fernández made clear, drawing a distinction between the document, which he said was of high doctrinal importance, as opposed to the recent statement allowing blessings for same-sex Catholics. The church teaches that “homosexual acts are intrinsically disordered.”

In an echo of the tension between the substance of church law and Francis’ style of a papal inclusivity, Cardinal Fernández said on Monday that perhaps the “intrinsically disordered” language should be modified to better reflect that the church’s message that homosexual acts could not produce life.

“It’s a very strong expression and it requires explanation,” he said. “Maybe we could find an expression that is even clearer to understand what we want to say.”

Though receptive to gay and transgender followers, the pope has also consistently expressed concern about what he calls “ideological colonization,” the notion that wealthy nations arrogantly impose views — whether on gender or surrogacy — on people and religious traditions that do not necessarily agree with them. The document said “gender theory plays a central role” in that vision and that its “scientific coherence is the subject of considerable debate among experts.”

Using “on the one hand” and “on the other hand,” language, the Vatican’s office on teaching and doctrine wrote that “it should be denounced as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation.”

“At the same time,” it continued, “the church highlights the definite critical issues present in gender theory.”

On Monday, Cardinal Fernández also struggled to reconcile the two seemingly dissonant views.

“I am shocked having read a text from some Catholics who said, ‘Bless this military government of our country that created these laws against homosexuals,’” Cardinal Fernández said on Monday. “I wanted to die reading that.”

But he went on to say that the Vatican document was itself not a call for decriminalization, but an affirmation of what the church believed. “We shall see the consequences,” he said, adding that the church would then see how to respond.

In his presentation, Cardinal Fernández described the long process of the drafting of a document on human dignity, “Infinite Dignity,” which began in March 2019, to take into account the “latest developments on the subject in academia and the ambivalent ways in which the concept is understood today.”

In 2023, Francis sent the document back with instructions to “highlight topics closely connected to the theme of dignity, such as poverty, the situation of migrants, violence against women, human trafficking, war, and other themes.” Francis signed off on the document on March 25.

The long road, Cardinal Fernández wrote, “reflects the gravity” of the process.

In the document, the Vatican embraced the “clear progress in understanding human dignity,” pointing to the “desire to eradicate racism, slavery, and the marginalization of women, children, the sick, and people with disabilities.”

But it said the church also sees “grave violations of that dignity,” including abortion, euthanasia, the death penalty, polygamy, torture, the exploitation of the poor and migrants, human trafficking and sex abuse, violence against women, capitalism’s inequality and terrorism.

The document expressed concern that eliminating sexual differences would undercut the family, and that a response “to what are at times understandable aspirations,” will become an absolute truth and ideology, and change how children are raised.

The document argued that changing sex put individualism before nature and that human dignity as a subject was often hijacked to “justify an arbitrary proliferation of new rights,” as if “the ability to express and realize every individual preference or subjective desire should be guaranteed.”

Cardinal Fernández on Monday said that a couple desperate to have a child should turn to adoption, rather than surrogacy or in vitro fertilization because those practices, he said, eroded human dignity writ large.

Individualistic thinking, the document argues, subjugates the universality of dignity to individual standards, concerned with “psycho-physical well-being” or “individual arbitrariness or social recognition.” By making dignity subjective, the Vatican argues, it becomes subject to “arbitrariness and power interests.”

Jason Horowitz is the Rome bureau chief for The Times, covering Italy, the Vatican, Greece and other parts of Southern Europe. More about Jason Horowitz

Elisabetta Povoledo is a reporter based in Rome, covering Italy, the Vatican and the culture of the region. She has been a journalist for 35 years. More about Elisabetta Povoledo

Vatican says sex reassignment surgery, surrogacy and gender theory threaten human 'dignity'

The Vatican has declared gender confirmation operations and surrogacy as grave threats to human "dignity", putting them on par with abortion and euthanasia as practices that violate God's plan for human life.

The Vatican's doctrine office on Monday published a 20-page declaration titled Infinite Dignity that was in the works for the past five years.

It was approved for publication by Pope Francis on March 25 after substantial revision in recent months.

In its most eagerly anticipated section, the Vatican reiterated its rejection of "gender theory" or the idea that one's gender can be "a self-determination".

It said God created man and woman as biologically different, separate beings, and said they must not tinker with that plan or try to "make oneself God".

"It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception," the document said.

It distinguished between transitioning surgeries, which it rejected, and "genital abnormalities" that are present at birth or that develop later. Those abnormalities can be "resolved" with the help of health care professionals, it said.

The document's existence, rumoured since 2019, was confirmed in recent weeks by the new prefect of the Dicastery for the Doctrine of the Faith, Argentine Cardinal Víctor Manuel Fernández, a close confidante of Pope Francis.

He had cast it as something of a nod to conservatives after he authored a more explosive document approving blessings for same-sex couples that sparked criticism from conservative bishops around the world, especially in Africa.

While the new document rejected gender theory, it took pointed aim at countries — including many in Africa — that criminalise homosexuality.

It echoed Pope Francis's assertion in a 2023 interview that "being homosexual is not a crime", making the assertion now part of the Vatican's doctrinal teaching.

It denounced "as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation".

The document restated well-known Catholic doctrine opposing abortion and euthanasia.

It also added to the list some of Pope Francis's main concerns as pope: the threats to human dignity posed by poverty, war, human trafficking and forced migration.

A child's right to 'a fully human origin'

In a newly articulated position, the declaration said surrogacy violated both the dignity of the surrogate mother and the child.

While much attention on surrogacy has focused on possible exploitation of poor women as surrogates, the Vatican document focuses more on the resulting child.

"The child has the right to have a fully human (and not artificially induced) origin and to receive the gift of a life that manifests both the dignity of the giver and that of the receiver," the document said.

"Considering this, the legitimate desire to have a child cannot be transformed into a 'right to a child' that fails to respect the dignity of that child as the recipient of the gift of life."

The Vatican published its most articulated position on gender in 2019, when the Congregation for Catholic Education rejected the idea that people can choose or change their genders.

It insisted on the complementary nature of biologically male and female sex organs to create new life.

Gender fluidity was described as a symptom of the "confused concept of freedom" and "momentary desires" that characterise post-modern culture.

The new document from the more authoritative Dicastery for the Doctrine of the Faith quoted from that 2019 education document but tempered the tone.

Significantly, it did not repurpose the 1986 language of a previous doctrinal document saying that homosexual people deserve to be treated with dignity and respect but that homosexual actions are "intrinsically disordered".

Francis has made reaching out to LGBTQ+ people a hallmark of his papacy, ministering to trans Catholics and insisting that the Catholic Church must welcome all children of God.

But he has also denounced "gender theory" as the "worst danger" facing humanity today, describing it as an "ugly ideology" that threatens to cancel out God-given differences between man and woman.

"It needs to be emphasised that biological sex and the sociocultural role of sex (gender) can be distinguished but not separated," the new document said.

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Reporting by Jessie Pang and Dorothy Kam in Hong Kong; Additional reporting by Laurie Chen in Beijing; Editing by Farah Master and Nick Macfie

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Jessie Pang joined Reuters in 2019 after an internship. She covers Hong Kong with a focus on politics and general news.

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Doctrine says gender-affirming surgery and surrogacy reject god's plan for human life.

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Transgender activists and allies on Monday decried the Vatican's new doctrine against gender-affirming surgery as "hurtful" and devoid of the voices and experiences of trans, non-binary and gender-diverse people, especially in its distinction between transgender and intersex people.

"The suggestion that gender-affirming health care — which has saved the lives of so many wonderful trans people and enabled them to live in harmony with their bodies, their communities and (God) — might risk or diminish trans people's dignity is not only hurtful but dangerously ignorant," said Mara Klein, a non-binary, transgender activist who has participated in Germany's church reform project.

"Seeing that, in contrast, surgical interventions on intersex people — which if performed without consent especially on minors often cause immense physical and psychological harm for many intersex people to date — are assessed positively just seems to expose the underlying hypocrisy further," Klein said.

The Vatican on Monday declared gender-affirming surgery as well as surrogacy as grave violations of "human dignity," putting them on par with abortion and euthanasia as practices that it says rejects God's plan for human life.

The Vatican's doctrine office issued "Infinite Dignity," a 20-page declaration that has been in the works for five years. After substantial revision in recent months, it was approved March 25 by Pope Francis, who ordered its publication.

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In its most eagerly anticipated section, the Vatican repeated its rejection of what it calls "gender theory," or the idea that one's gender can be changed. Gender theory, often called gender ideology by its detractors, suggests that gender is more complex and fluid than the binary categories of male and female, and depends on more than visible sex characteristics.

The term "gender theory" is often used to suggest that trans and non-binary people have a political agenda.

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"It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception," the document said. 

It distinguished between gender-affirming surgeries, which it rejected, and what it called "genital abnormalities" that are present at birth or that develop later. Those abnormalities can be "resolved" with the help of health-care professionals, it said.

The Vatican's use of "sex-change" is also considered a loaded term by transgender advocates. The Trans Journalists Association notes that "sex-change" and "sex reassignment" are outdated terms and "are now generally considered offensive, though some medical literature still uses them. Some organizations with anti-trans political goals also use these phrases in lieu of gender-affirming care."

Warnings document could fuel hate and violence

Advocates for 2SLGBTQ+ Catholics immediately criticized the document as outdated, harmful and contrary to the stated goal of recognizing the "infinite dignity" of all of God's children. They warned it could have real-world effects on trans people, fuelling anti-trans violence and discrimination.

"While it lays out a wonderful rationale for why each human being, regardless of condition in life, must be respected, honoured, and loved, it does not apply this principle to gender-diverse people," said Francis DeBernardo of New Ways Ministry, which advocates for 2SLGBTQ+ Catholics.

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The document's existence, rumoured since 2019, was confirmed in recent weeks by the new prefect of the Dicastery for the Doctrine of the Faith, Argentine Cardinal Víctor Manuel Fernández, a close Francis confidant. 

The document comes at a time of some backlash against transgender people, including in the United States where Republican-led state legislatures are considering a new round of bills restricting medical care for transgender youths — and in some cases, adults.

Pope's stance on gender angers some Catholics

In addition, bills to govern youths' pronouns, sports teams and bathrooms at school are also under consideration, as well as some books and school curriculums.

"On top of the rising hostility toward our communities, we are faced with a church that does not listen and refuses to see the beauty of creation that can be found in our biographies," Klein said.

Francis has made reaching out to 2SLGBTQ+ people a hallmark of his papacy, ministering to trans Catholics and insisting that the Catholic Church must welcome all children of God.

But he has also denounced "gender theory" as the "worst danger" facing humanity today, an "ugly ideology" that threatens to cancel out what the church considers as God-given differences between man and woman.

He has blasted in particular what he calls the "ideological colonization" of the West in the developing world, where development aid is sometimes conditioned on adopting Western ideas about gender and reproductive health.

With files from CBC News

Hong Kong Amends Its Surgery Requirements to Change Gender Markers on IDs

H ong Kong no longer requires transgender people to undergo full gender-affirming surgery to change their legal gender markers in their IDs, more than a year after the Chinese enclave’s top court called the requirement unconstitutional.

The government announced the change on Wednesday, “having prudently considered the objective of the policy, relevant legal and medical advice, as well as drawing reference from the relevant practices overseas.”

Under the new rules, Hong Kong residents who have not undergone full sex reassignment surgery [SRS] who want to have their gender marker on their ID changed still must have completed select surgical treatment to modify their sexual characteristics—removal of the breasts for transgender men, removal of the penis and testes for transgender women—along with medical documentation. Previous guidelines required the removal of the uterus and ovaries or the construction of a penis or “some form” of it for female-to-male transition, and the removal of the penis and testes and the construction of a vagina for male-to-female transition.

“We are still concerned about the heavy emphasis on sex reassignment surgeries being a requirement,” Wong Hiu-chong, the lawyer for transgender activist Henry Tse , whose case led to the policy change, told TIME. “SRS can be life threatening.”

Those who wish to change their gender markers must also statutorily declare that they have gender dysphoria—the medical term for the psychological distress a person feels when their gender identity does not match with their assigned sex at birth—and have lived as the opposite sex for at least two years before their application. They must also show proof of receiving hormonal treatment throughout the previous two years, and will be subjected to random blood tests to check their hormonal profile.

“Our clients have waited a very long time for such an unconstitutional policy to be revised, and for them, the wait has been painful,” Wong said in a statement. She also questioned the need for blood tests, calling this requirement, among others that remain for gender marker changes, “potentially discriminatory” as it does not apply to other Hong Kong ID card holders.

A government spokesperson clarified in the announcement that the gender marker change will only apply to the Hong Kong Identity Card and that “the sex entry on a Hong Kong identity card does not represent the holder’s sex as a matter of law. It does not affect any other policies of the Government or the handling of any other gender-related matters under the law in Hong Kong or relevant legal procedures.”

The policy change comes years after Tse filed a case in 2017 to question the full gender-affirming surgery requirement. Despite the city’s Court of Final Appeal issuing a ruling deeming the requirement unconstitutional in February 2023, implementation of the ruling was long-delayed, which Tse also challenged . The ruling said “such surgical procedures are at the most invasive end of the treatment spectrum” and that “full SRS is not medically required by many transgender persons whose gender dysphoria has been effectively treated.”

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