gender identity reassignment therapy

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• Diseases & Conditions
• Gender dysphoria

Your health care provider might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. Your provider will also ask about the degree of support you have from family, chosen family and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. It involves feelings of distress due to a strong, pervasive desire to be another gender.

Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Others might instead show symptoms of a mood disorder, anxiety or depression. Or they might experience social or academic problems.

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Our caring team of Mayo Clinic experts can help you with your gender dysphoria-related health concerns Start Here

Treatment can help people who have gender dysphoria explore their gender identity and find the gender role that feels comfortable for them, easing distress. However, treatment should be individualized. What might help one person might not help another.

Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of gender-diverse people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the chest, external genitalia, internal genitalia, facial features and body contour

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair.

Treatments are based on your goals and an evaluation of the risks and benefits of medication use. Treatments may also be based on the presence of any other conditions and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Legal age in a person's country or, if younger, following the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pre-treatment medical evaluation is done by a doctor with experience and expertise in transgender care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments This evaluation may include:

• A personal and family medical history
• A physical exam
• Assessment of the need for age- and sex-appropriate screenings
• Identification and management of tobacco use and drug and alcohol misuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo or ovarian tissue cryopreservation
• Documentation of history of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria.

The goal of behavioral health treatment is to help you feel comfortable with how you express your gender identity, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couples, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of the stress that results from experiencing prejudice and discrimination because of your gender identity (minority stress)
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A behavioral health evaluation may not be required before receiving hormonal and surgical treatment of gender dysphoria, but it can play an important role when making decisions about treatment options. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance misuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

More Information

Gender dysphoria care at Mayo Clinic

• Pubertal blockers
• Feminizing hormone therapy
• Feminizing surgery
• Gender-affirming (transgender) voice therapy and surgery
• Masculinizing hormone therapy
• Masculinizing surgery

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Mental health care. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about any anxiety or depression you're experiencing.
• Support groups. Talking to other transgender or gender-diverse people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritizing self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditation or prayer. You might find comfort and support in your spirituality or faith communities.
• Getting involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for your appointment

You may start by seeing your primary care provider. Or you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms , including any that seem unrelated to the reason for your appointment
• Key personal information , including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your health care provider
• Ferrando CA. Comprehensive Care of the Transgender Patient. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Hana T, et al. Transgender health in medical education. Bulletin of the World Health Organization. 2021; doi:10.2471/BLT.19.249086.
• Kliegman RM, et al. Gender and sexual identity. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Ferri FF. Transgender and gender diverse patients, primary care. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Nov. 8, 2021.
• Keuroghlian AS, et al., eds. Nonmedical, nonsurgical gender affirmation. In: Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Nov. 8, 2021.
• Coleman E, et al. Surgery. In: Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Version 7. World Professional Association for Transgender Health; 2012. https://www.wpath.org/publications/soc. Accessed Nov. 3, 2021.

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Gender reassignment therapy

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Gender reassignment therapy is an umbrella term for all medical procedures regarding gender reassignment of both transgender and intersexual people. (Sometimes also called sex reassignment, as it alters physical sexual characteristics to be more in line with the individual’s psychological/social gender identity, rather than vice versa.)

Gender reassignment therapy consists of hormone replacement therapy (HRT), various surgical procedures (see below), and epilation for transwomen, that is permanent hair removal on the face and body is accomplished with electrolysis or laser hair removal.

Transsexual people who go through gender reassignment therapy usually change their social gender roles, legal names, and legal sex designation, in addition to undergoing the medical procedures discussed in this article. The entire process of change from one gender presentation to another is known as transition.

Sex reassignment surgery is the most common term for what would be more accurately described as genital reassignment surgery or genital reconstruction surgery . This refers to the procedures used to make male genitals in to female genitals and vice versa. Sex reassignment surgery, or SRS, can also refer to any surgical procedures which will reshape a male body into a body with a female appearance or vice versa.

Surgical procedures related to gender reassignment

For trans men , who transition from female to male:

• Sexual reassignment surgery female-to-male
• Mastectomy is the removal of female breasts and, in case of gender reassignment, the shaping of a male contoured chest.
• Hysterectomy is the removal of female internal sex organs.
• Metoidioplasty is the construction of a small penis out of the clitoris which has been enlarged by HRT
• Phalloplasty is specifically the construction of a neo-penis in transmen

For trans women , who transition from male to female:

• Sexual reassignment surgery male-to-female
• Vaginoplasty The shaping of a neo-vagina
• Penile inversion – the most common form of genital reassignment surgery.
• Colovaginoplasty – a particular form of genital reassignment surgery.
• Breast augmentation is the enlargement of breasts, which can be necessary if HRT did not yield satisfactory results.
• Facial feminization surgery

Requirements

The requirements for hormone replacement therapy vary greatly, often at least a certain time of psychological counseling is required, and so is a time of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role.

Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the opposite gender in all possible ways for at least a year (“cross-live”) prior to the start of surgery in order to assure that they can psychologically function in that life-role. This period is sometimes called the Real Life Test (RLT); it is part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for this surgery.

Most professionals in the USA who provide services to transsexual women and men follow the controversial Standards of Care for Gender Identity Disorders put forth by the Harry Benjamin International Gender Dysphoria Association. Outside the USA, many other SOCs, protocols and guidelines exist, although the Harry Benjamin SOCs are certainly the best known. There exists a significant and growing political movement to redefine the SOC, asserting that they do not acknowledge the rights of self-determination and control over one’s body, and that they expect (and even in many ways requires) a monolithic transsexual experience when in reality there are as many different ways of being transsexual as there are transsexual people. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from “making a mistake” and causing irreversible changes to their bodies that will later be regretted — though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.

Controversy

Although the overwhelming majority of individuals who undergo gender reassignment are forever happy and content living as members of their target sex, some people still believe that gender reassignment is ineffective as a treatment for transsexuality, or that it is “wrong” and/or “immoral.”

Many religious conservatives believe that physical gender reassignment is sinful, and therefore cite evidence that transsexuality can be cured spiritually or psychologically. However, substantial evidence suggests that psychological treatments for transsexuality are highly ineffective.

Although it is undeniably offensive to transsexual women and men, some people consider transsexuals to be members of the physical sex assigned to them at birth, even after they have completed all aspects of gender reassignment. Their reasoning is often based in the facts that sex chromosomes cannot be changed with the procedures currently available, and that transsexuals do not have reproductive organs. Many other people believe that an individual’s sex is determined by factors such as gender presentation, gender identity, external genitalia, and sex hormones; and therefore, they consider transsexuals to be true members of their target sex. They often point to otherwise “normal” women and men who were either born without certain reproductive organs, or had them removed, as well as the existence of people whose sex chromosomes do not match their physical sex and gender identity, such as women with Complete Androgen Insensitivity Syndrome.

In 1967, John Money, a prominent sexologist at Johns Hopkins Hospital, recommended that David Reimer , a boy who had lost his penis during a botched circumcision, be sexually reassigned and raised as a girl. Despite being raised as a girl from the age of 18 months, Reimer was never happy as a girl, and when he learned of his sex reassignment, he immediately reverted to living as a male. Money never reported on the negative outcome of Reimer’s case, but in 1997, Reimer went public with the story himself. His case, as well as several cases of intersexed infants with conditions such as cloacal exstrophy who have been reassigned and raised as females, suggest that gender identity is innate and immutable.

In 1979, when Paul McHugh became chairman of the psychiatric department at Johns Hopkins, he ordered the department to conduct follow-up evaluations on as many of their former transsexual patients as possible. When the follow-ups were performed, they found that most of the patients claimed to be happy as members of their target sex, but that their overall level of psychological functioning had not improved. McHugh reasoned that to perform physical gender reassignment was to “cooperate with a mental illness rather than try to cure it.” At that time, Johns Hopkins closed its gender clinic and has not performed any sex reassignment surgeries since then. Many people have criticized McHugh’s conclusion, often stating their belief that the purpose of gender reassignment is to make transsexual people happy and content with their bodies, not to improve their psychological functioning.

Many medical textbooks state that “significant psychological problems often persist after surgical and hormonal sex reassignment.” However, these texts do not cite reputable sources on which they base their conclusions. Much less research has been done on transsexuality than on many other conditions such as Down syndrome, Cerebral palsy, and autism. However, many people, especially transsexual people, feel that physical gender reassignment is a highly effective treatment for transsexuality, and that medical researchers should have higher priorities than transsexuality. This is especially true of those who feel that “mainstream” medical professionals who research transsexuality are attempting to find ways to cure the condition psychologically; many transsexual people feel that physical gender reassignment is a far better treatment for their gender dysphoria than any psychological treatment or other treatment to “change the mind to match the body” rather than vice versa, ever would be.

Most of the published studies regarding gender reassignment are widely believed to be biased.

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• April 01, 2024 | VOL. 181, NO. 4 CURRENT ISSUE pp.255-346
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Treatment of Gender Identity Disorder

• William Byne , M.D., Ph.D. ,
• Susan J. Bradley , M.D. ,
• Eli Coleman , Ph.D. ,
• A. Evan Eyler , M.D., M.P.H. ,
• Richard Green , M.D., J.D. ,
• Edgardo Menvielle , M.D. ,
• Heino F.L. Meyer-Bahlburg , Dr. rer. nat. ,
• Richard R. Pleak , M.D. , and
• D. Andrew Tompkins , M.D.

Search for more papers by this author

At its September 2011 meeting, the Board of Trustees (BOT) of the American Psychiatric Association (APA) voted to approve as a Resource Document the report of the Task Force on Treatment of Gender Identity Disorder (GID). Both the diagnosis and treatment of GID are controversial as reflected in the professional literature as well as in popular discourse where they have recently garnered considerable attention. In contrast to the treatment of other DSM diagnoses where emphasis is on changing thoughts, feelings and behaviors, the treatment of GID from adolescence onward often emphasizes modification of the body. Although psychiatric diagnosis and treatment are inextricably linked, they are separate issues and the DSM does not evaluate and compare the benefits and risks of alternative treatments. As the DSM-V workgroups were deliberating, the BOT, therefore, formed a task force to address concerns that go beyond those in the purview of the DSM-V work group addressing GID. The Task Force was charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to present a report to the BOT that would include an opinion as to whether or not sufficient credible literature exists for the APA to take the next step and develop treatment recommendations. Separate sections of the report assess the treatment literature in children, adolescents, adults, and individuals of any age with disorders of sex development (DSDs, aka intersex conditions; DSM-IV criterion C excludes individuals with DSDs from the diagnosis of GID. If they meet other criteria, they receive the diagnosis of GID Not Otherwise Specified. The current DSM-5 proposal recommends replacing GID with Gender Dysphoria and designating two subtypes, without and with a DSD.).

The randomized double blind control trial is the study design that affords the highest quality evidence regarding the comparative efficacy of alternative treatments; however, no such trials have been conducted to address any aspect of the treatment of GID. Given the very nature of GID, such trials, or even unblinded trials with random assignment to treatment groups, are not likely to be forthcoming due to a lack of feasibility and/or ethical concerns. Absent such studies, the quality of evidence pertaining to most aspects of treatment for GID was determined to be low. The Task Force, therefore, delineated aspects of treatment where broad clinical consensus appears to be either present or lacking. The Task Force concluded that consensus is sufficient to support recommendations for the treatment of GID in all subgroups reviewed and that, with subjective improvement as the primary outcome measure, evidence is sufficient to support recommendations for the treatment of adults in the form of an APA Practice Guideline with gaps in the empirical database supplemented by clinical consensus.

While several existing guidelines, policy statements and standards of care are available to guide mental health professionals in providing care to individuals with GID, the report identifies several reasons that recommendations specifically targeted to psychiatrists would be desirable. Although the practice of psychiatry overlaps with that of other mental health fields, psychiatry is unique in several respects. Psychiatry often has the primary role in the diagnosis and treatment of the major mental illnesses in which gender identity concerns may arise as epiphenomena (e.g., psychotic disorders) as well as in the pharmacological management of psychiatric disorders that may coexist with GID (e.g., mood and anxiety disorders), and in monitoring symptoms that may emerge with endocrine manipulation. By virtue of their medical training, psychiatrists are in a unique position among mental health professionals to liaise with other medical specialists who provide GID care. Further, recommendations from the APA would facilitate opportunities for training in the provision of services to individuals with GID and address the current shortage of mental health professionals working in this area.

The report recommends that additional steps pertaining to gender variance (GV) be taken by the APA beyond drafting treatment recommendations for GID. These include issuing a policy statement to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments for minors with GID or GV, and the rights of persons of any age who are gender variant, transgender or transsexual.

The full Resource Document accompanies the online version of this APA Official Action ( ajp.psychiatryonline.org ).

Dr. Byne is the Task Force Chair.

From the Department of Psychiatry, Mount Sinai School of Medicine, New York, and the Mental Illness Education, Research and Clinical Center, JJ Peters VA Medical Center, Bronx, NY (W.B.); the Center for Addiction and Mental Health and Hospital for Sick Children, Toronto (S.J.B.); the Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis (E.C.); the Departments of Family Medicine and Psychiatry, University of Vermont College of Medicine, Burlington (A.E.E.); the Department of Psychiatry, University of California, Los Angeles (R.G.); the Departments of Psychiatry and Behavioral Sciences, The George Washington University and Children's National Medical Center, Washington, DC, (E.M.); the New York State Psychiatric Institute and the Department of Psychiatry, Columbia University, New York, (H.F.L.M.-B.); the Department of Psychiatry, Hofstra North Shore-LIJ School of Medicine and Department of Clinical Psychiatry & Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY (R.R.P.); and the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (D.A.T.).

• Behandlungstechnische Herausforderungen bei Jugendlichen mit Geschlechtsdypshorie und Persönlichkeitsstörung 1 March 2024 | PTT - Persönlichkeitsstörungen: Theorie und Therapie, Vol. 28, No. 1
• Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice 9 November 2023 | Australasian Psychiatry, Vol. 32, No. 1
• The Nexus between Gender-Confirming Surgery and Illness Journal of Middle East Women's Studies, Vol. 18, No. 3
• Behavioral and neurobiological effects of GnRH agonist treatment in mice—potential implications for puberty suppression in transgender individuals 12 September 2020 | Neuropsychopharmacology, Vol. 46, No. 5
• Early adolescent gender diversity and mental health in the Adolescent Brain Cognitive Development study 28 May 2020 | Journal of Child Psychology and Psychiatry, Vol. 62, No. 2
• The Lancet, Vol. 388, No. 10042
• Commentary on Kraus’ (2015) “Classifying Intersex in DSM-5: Critical Reflections on Gender Dysphoria” 14 July 2015 | Archives of Sexual Behavior, Vol. 44, No. 7
• Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment 1 October 2014 | Pediatrics, Vol. 134, No. 4
• The Politics of Psychoanalytic Lexicography 9 June 2014 | Journal of the American Psychoanalytic Association, Vol. 62, No. 3
• The Psychoanalytic Study of the Child, Vol. 68, No. 1
• Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder 1 January 2014 | The Journal of Sexual Medicine, Vol. 11, No. 1
• Evaluation and management of children and adolescents with gender identification and transgender disorders Current Opinion in Pediatrics, Vol. 25, No. 4

Therapy/Counseling: Gender Transition

Gender transition therapy, also known as gender-affirming therapy, is a comprehensive and individualized process that supports individuals in aligning their physical appearance, social roles, and legal identity with their gender identity. This process may involve medical interventions, psychological counseling, and social support to help individuals achieve a sense of congruence and well-being.

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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.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

Gender Therapy Demystified: A Roadmap to Exploring, Naming, and Affirming Your Gender

Introduction

Did you know that questioning your gender is a completely normal and even healthy part of discovering who you are? It’s true. Exploring and understanding your gender identity can be a deeply personal and transformative experience, leading to a more authentic and fulfilling life. And guess what? It doesn’t automatically mean you’re transgender, nonbinary, or gender non-conforming unless, of course, that’s what you discover about yourself after some thoughtful consideration. It means you’re taking the time to get to know yourself better, and that’s a wonderful thing.

As conversations surrounding gender continue to evolve and become more inclusive, I want to write this blog post to make sure you feel comfortable and supported while you’re on this journey. You’re not alone in questioning your gender, and it’s vital to remember that it’s perfectly okay to examine and embrace your unique gender experience. After all, you deserve to be your truest self.

The Role of Gender Therapy in Self-Discovery

So, where does gender therapy come in? Well, it can be a game-changer for people navigating the complexities of gender identity. By working with a trained and experienced gender therapist, you get the chance to explore your feelings, thoughts, and experiences related to gender in a safe and supportive environment.

Gender therapy can provide you with the tools and guidance needed to better understand yourself and develop a strong sense of identity. Whether you end up identifying as transgender, cisgender, or something else entirely, this journey can be an incredibly rewarding and enriching experience. Let’s explore this, here.

Common Struggles and Fears in Questioning Gender: You’re Not Alone

Feeling out of place or uncomfortable with assigned gender roles.

Hey, guess what? If you’re questioning your gender, you might experience a sense of discomfort or disconnect with the gender roles assigned to you at birth. And that’s completely normal. This feeling can show up as a persistent unease with societal expectations or how others perceive your body. Part of the questioning process involves examining these feelings and figuring out how they relate to your identity. Just remember that you’re not alone in feeling this way.

Fear of Disclosing Feelings to Friends and Family

I get it – opening up about your gender exploration can be pretty daunting, especially when you’re still figuring things out for yourself. The fear of being misunderstood, judged, or rejected can make it tough to share these deeply personal experiences with loved ones. But here’s the thing: disclosing your feelings is a personal choice, and there’s no “right” or “wrong” time to let others in on your journey. You get to decide what works best for you.

Doubting Your Authentic Gender Identity

Questioning your gender can come with a side of uncertainty, and that might lead you to doubt the authenticity of your feelings and experiences. Society’s pressure to conform to traditional gender roles and other people’s expectations can make this doubt even more intense. But don’t worry – gender therapy is here to support you. This type of therapy offers a safe space to explore your doubts and fears, guiding you toward a deeper understanding of your true self.

Gender Therapy: What It Is and What It Isn’t

Goals and focuses of gender therapy.

So, let me tell you a little bit about gender therapy. It’s a specialized form of counselling that focuses on addressing the unique needs and concerns of people like you – those who are questioning their gender or facing gender-related challenges. The main goals? Helping you explore your gender identity, develop a deeper understanding of yourself, and navigate any emotional, social, or physical challenges related to gender. Plus, gender therapy aims to empower you to make informed decisions about your gender expression and any medical interventions you might be considering.

The Importance of a Gender-Affirming Approach

One essential aspect of gender therapy is using a gender-affirming approach. This means recognizing that gender diversity is a natural and healthy part of being human. The approach emphasizes the importance of respecting and validating each person’s gender identity and expression, no matter if they identify as cisgender, transgender, nonbinary, or something else. By creating an environment of acceptance and support, gender therapists like me can help you feel more comfortable and confident as you explore your true self.

Misconceptions and Potential Pitfalls in Gender Therapy

Now, let’s clear up some misconceptions and potential pitfalls surrounding gender therapy. First off, gender therapists shouldn’t begin by diagnosing your gender identity or changing or dissuading them from your feelings. The focus should always be on providing information, support, and guidance to help you better understand yourself and your gender. That’s what it’s all about.

Understanding Gender Dysphoria: Let’s Talk About It

Definition and the distinction between diagnosis and experience.

First, let me explain what gender dysphoria is. It refers to the distress or discomfort that can arise from a mismatch between the sex assigned to someone at birth and their gender identity. It’s important to distinguish between the medical diagnosis of gender dysphoria and the subjective experience of dysphoric feelings. Some individuals may meet the criteria for a clinical diagnosis, while others may experience dysphoric feelings without meeting the diagnostic threshold.

The Evolution of the Term and Its Impact on the Transgender Community

Over time, our understanding and use of the term gender dysphoria have evolved. In 2013, the American Psychiatric Association replaced the outdated term “gender identity disorder” with “gender dysphoria.” This shift emphasizes the distress associated with the experience, rather than labelling the gender identity itself as disordered. This change has helped reduce stigma and promote greater acceptance and understanding of transgender individuals.

The Role of Gender Therapy in Managing Dysphoria

Gender therapy can be instrumental in helping you understand, manage, and minimize gender dysphoria. By providing a supportive environment and evidence-based interventions, gender therapists like me can help you explore your feelings, develop coping strategies, and make informed decisions about potential medical or nonmedical interventions to alleviate dysphoria.

Gender Exploration, Expression, and Affirmation

Reasons people seek out gender therapy.

People seek out gender therapy for various reasons, including exploring their gender identity, supporting a loved one navigating gender issues, accessing gender-affirming interventions, addressing gender dysphoria, or managing mental health concerns more generally. Gender therapy can provide valuable guidance and support throughout these processes.

Medical and nonmedical gender-affirming interventions

There are numerous medical and nonmedical gender-affirming interventions available to help individuals explore, express, and affirm their gender. Medical interventions may include hormone therapy, surgeries, and other procedures, while nonmedical interventions can involve changes in language, name, pronouns, clothing, or other aspects of presentation. Gender therapists can help clients navigate these options and determine which interventions are most appropriate for their unique needs and goals.

The importance of individualized care

Every person’s journey with gender is different, and it’s essential that gender therapy is tailored to meet the specific needs and goals of each client. By providing individualized care, gender therapists can create a safe, supportive, and affirming space for clients to explore their gender identity, navigate potential challenges, and make informed decisions about their path forward.

In conclusion, gender therapy is a vital resource for individuals questioning their gender, experiencing gender dysphoria, or seeking guidance and support in their gender journey. By providing a gender-affirming approach and individualized care, gender therapists can help clients explore, express, and affirm their true selves, ultimately contributing to a more fulfilling and authentic life.

Gatekeeping vs. Informed Consent in Gender Therapy

The challenges of accessing gender-affirming care.

Accessing gender-affirming care can be a complex and frustrating process for many people. Oftentimes, medical guidelines and insurance policies require letters from licensed mental health professionals to access hormone therapy or surgeries. This can create barriers and delays in receiving the care that individuals need and deserve.

Criticisms of gatekeeping

Gatekeeping refers to the restrictive power structures set up by the medical establishment, professional associations, and insurance companies that create unnecessary obstacles for individuals seeking gender-affirming care. It has been heavily criticized by the transgender community and in academic literature for perpetuating stigmatization, discrimination, and barriers to accessing vital healthcare services.

The informed consent model and its benefits

The informed consent model of care aims to counteract the harmful effects of gatekeeping by centring individual agency and autonomy in decision-making. This approach empowers people to make informed decisions about their own gender-related healthcare needs. Gender therapists who use this model educate clients about their full range of options, enabling them to make well-informed choices about their care. Informed consent is gaining traction, and an increasing number of gender clinics, medical providers, and health insurance policies are beginning to support this model for accessing puberty blockers and hormone therapy.

Finding the Right Gender Therapist

Challenges in locating a qualified therapist.

Finding a qualified gender therapist can be both practically and emotionally challenging. It’s crucial to locate a therapist who has the necessary training and experience to provide the support and guidance needed to navigate the complexities of gender identity and expression.

Questions to ask potential therapists to gauge their expertise

When evaluating potential gender therapists, it’s essential to ask about their professional training and experience working with clients who are transgender, nonbinary, or gender-questioning. Sample questions may include:

• How often do you work with transgender, nonbinary, and gender-questioning clients?
• Where did you receive education and training about gender, transgender health, and providing gender therapy?
• What is your process and approach for providing letters of support for gender-affirming interventions?
• Do you offer remote sessions using telehealth?

These questions can help you determine whether a potential gender therapist has the expertise and approach that will work best for you.

Importance of finding a good fit for your needs

Just as important as finding a qualified therapist is finding one who is a good fit for your individual needs and preferences. The right therapist should make you feel comfortable, supported, and respected as you explore your gender identity and navigate any challenges that may arise. By taking the time to find the right therapist, you can ensure a more positive and productive experience in gender therapy.

The Power of Supportive Communities

The value of finding peers and communities, both online and offline.

Finding supportive communities and connecting with peers who share similar experiences and feelings can be incredibly valuable in one’s journey of gender exploration. Engaging with others who are questioning their gender, or identifying as transgender, or nonbinary can foster a sense of belonging, reduce feelings of isolation, and provide a wealth of knowledge and resources. Online forums, social media groups, and in-person support groups are all excellent ways to find these communities and build connections.

The role of support networks in gender exploration and therapy

Support networks, including friends, family, and supportive communities, play a crucial role in one’s gender exploration and therapy process. These networks can provide emotional support, practical advice, and encouragement during difficult moments. They can also help individuals to build resilience, overcome internalized stigma, and advocate for their rights and needs within the healthcare system. Gender therapists often encourage clients to build and maintain strong support networks to facilitate their growth and progress.

The journey toward self-discovery and understanding one’s gender

The journey of understanding and embracing one’s gender identity is unique and personal. It can be a challenging, affirming, and transformative process. Gender therapy can serve as an essential resource for self-discovery and provide support, guidance, and validation as individuals explore their gender identity and expression.

The importance of gender therapy and support networks

Gender therapy and strong support networks are crucial components in navigating the complexities of gender identity and expression. Both can provide invaluable tools for self-discovery, empowerment, and affirmation. They can help individuals to overcome obstacles, challenge societal expectations, and live authentically in their true gender identity.

Affirming the right to feel comfortable and accepted in one’s gender and body

Ultimately, the goal of gender therapy and supportive communities is to empower individuals to feel comfortable, confident, and accepted in their gender and body. Every person has the right to explore and express their gender identity without fear of judgment or discrimination. By engaging in gender therapy and building supportive networks, individuals can take important steps toward living an authentic and fulfilling life.

Disclaimer : This blog shares general information only, not professional advice or recommendations. Consult healthcare providers for personal guidance. Decisions based on content are the reader's responsibility. Thank you.

Clayre Sessoms

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• Published: 22 May 2023

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

• David Matthew Doyle   ORCID: orcid.org/0000-0002-8010-6870 1 ,
• Tom O. G. Lewis   ORCID: orcid.org/0000-0001-9607-6568 2 &
• Manuela Barreto   ORCID: orcid.org/0000-0002-6973-7233 2  

Nature Human Behaviour volume  7 ,  pages 1320–1331 ( 2023 ) Cite this article

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• Endocrine system and metabolic diseases
• Human behaviour

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

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The most common form of medical intervention sought by transgender people (here we use this term to refer to anyone whose gender identity does not match their gender assigned at birth, for example, including non-binary, gender fluid and genderqueer people) is gender-affirming hormone therapy 1 , 2 . For example, approximately 60%–70% of those who attended the most widely used gender identity clinic in the Netherlands between 2010 and 2014 began hormone therapy within 5 years (ref. 3 ). Once on gender-affirming hormone therapy, transgender people are generally instructed to continue to use some dosage of gender-affirming hormones throughout their lives 4 , 5 . Transgender people tend to engage with these therapies to modify their physical presentation in line with their gender identity 6 , 7 ; importantly, sex hormones may also affect psychological states and social interactions, as is observed during puberty 8 . However, despite the large and growing prevalence of gender-affirming hormone therapy across countries 9 , no systematic review of research has been conducted to examine the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning among transgender people. Research in humans and non-human animals has suggested that hormones may influence psychosocial functioning via biological pathways 10 , 11 , 12 , 13 , but findings in this literature have often been mixed or inconclusive. There is a pressing need to better understand the psychosocial consequences of hormones, particularly given the critical implications for transgender health.

Psychosocial functioning is a core facet of human life that shapes how people relate to others and the quality of their social relationships. Psychosocial functioning refers to a variety of traits, characteristics and dispositions that have been broadly classified 14 as (1) well-being (for example, self-acceptance, positive mood, satisfaction with life), (2) self-mastery (for example, self-control, low aggression and impulsivity) and (3) interpersonal functioning (for example, trust, secure attachment, empathy). Better psychosocial functioning across these three domains has been shown to be associated with healthier experiences in social relationships, including higher quality romantic relationships 15 and friendships 16 , potentially decreasing social isolation and loneliness throughout the life course 17 . Worryingly, accumulating evidence points toward impairments in psychosocial functioning and greater negative experiences in social relationships among transgender people relative to cisgender populations, likely driven in part by experiences of stigma and invalidation 18 . For example, on average, transgender people report higher levels of social anxiety relative to cisgender people 19 . Decades of research have shown that social relationships are vital to health and well-being 20 , 21 , including longevity and mortality 22 . In perhaps the starkest example of how poor psychosocial functioning and negative experiences in social relationships may affect transgender people, suicide rates are substantially elevated in this group relative to cisgender people. Approximately one in three transgender people attempt suicide in their lifetime 23 , and past work has linked this risk in part to disruption in their social life 24 , 25 .

Transgender people can seek hormone therapies to affirm their gender identity, to aid with gender congruence and alleviate gender dysphoria. Gender-affirming hormone therapy usually involves exogenous administration of testosterone for transmasculine people, and oestradiol along with an anti-androgen for transfeminine people, as well as individualized treatments for those identifying as non-binary or gender diverse. Evidence suggests that gender-affirming hormone treatments reorganize brain structure and function 26 , which is in line with evidence demonstrating the general importance of sex steroids to neurobiology 27 , 28 . These fundamental neurobiological changes may in turn shape responses to social stimuli and general social functioning via biological processes 29 .

A growing body of research, principally from the field of social neuroendocrinology, has suggested that both endogenous and exogenous hormones influence psychosocial functioning via biological pathways 10 , 12 , 13 . A relatively large number of studies have found that exogenous administration of testosterone may affect various aspects of psychosocial functioning in cisgender men and women, including potentially increasing social aggression and decreasing emotion identification and trust, although such findings are still often tentative and inconclusive 30 . Comparatively less research has been devoted to studying the psychosocial effects of exogenous administration of oestrogens in humans, but some work suggests that they may improve mood in cisgender women, particularly for those diagnosed with depressive disorders 31 . Additionally, exogenous administration of progesterone has been linked to changes in mood in cisgender women in both positive and negative ways, depending on dose and other factors, such as history of premenstrual syndrome 32 .

Clinical guidance for the provision of gender-affirming care, particularly gender-affirming hormone therapy, relies on a relatively underdeveloped and somewhat inconsistent evidence base with little acknowledgement of potential psychosocial implications 33 , 34 . At best, in addition to potential medical side-effects (for example, increased risk of deep vein thrombosis for those on feminizing hormone therapies and increased risk of polycythaemia for those on masculinizing hormone therapies), clinical guidance 1 , 2 may mention the possibility of some changes in mood or personality, such as increased aggression following commencement of testosterone 35 , 36 . A few reviews have been conducted on the effects of gender-affirming hormone therapy on mental health and quality of life 37 , 38 , 39 , 40 , but each of these focused on just one dimension of psychosocial functioning (that is, well-being). Speaking to the societal relevance of this topic, some critics have pointed to a perceived lack of evidence for various outcomes in practice guidelines for gender-affirming hormone therapies as a reason to limit their use 41 , 42 . Therefore, a systematic review of changes in psychosocial functioning is useful to highlight outcomes for which there is strong evidence as well as to instigate further research on outcomes that need clarification.

The aim of the current review was to evaluate the state and quality of evidence for effects of gender-affirming hormone therapy on a wider range of dimensions of psychosocial functioning among transgender people. We sought to include studies with diverse research methodologies. The primary aim was to examine the strength of evidence for potential causal effects on psychosocial functioning resulting from gender-affirming hormone therapy. That is, we aimed to understand not only what effects hormone therapy might have on psychosocial functioning, but also whether these could be unambiguously and directly related to the hormonal changes, or whether existing evidence does not separate this from the various other changes that are associated with gender transition. To do so, we also formally assessed risk of bias for each study included in our review using the Newcastle-Ottawa Scale 43 —see Supplementary Tables 1 and 2 for full coding of each quantitative study—as well as coding for potential confounding variables (see Table 1 ) to gauge which were most often included in the quantitative literature on this topic.

Qualitative review

We identified only six (13% of all studies) qualitative studies (see Fig. 1 for study inclusion flowchart), all involving semistructured interviews. The total number of transgender participants across the qualitative studies was 171, with individual sample sizes ranging from 10 to 67 transgender participants per study. The qualitative research identified ( k  = 6, where k is the number of studies) predominantly involved participants on feminizing hormone therapy 44 , 45 , 46 , 47 , 48 , 49 , with only two studies 44 , 47 including participants on masculinizing hormone therapy. In the following sections we briefly summarize results related to changes in psychosocial functioning from the qualitative literature, organized by the experiences of those on feminizing and masculinizing hormone therapy separately.

PRISMA study inclusion flowchart.

Experiences on feminizing hormone therapy

Overall, the qualitative literature tended to support positive changes in well-being among people after starting feminizing hormone therapy, although often with the qualification that improvements in well-being were attributed to satisfaction with changes in appearance rather than to direct effects of hormones on psychosocial states 45 , 46 , 48 . More specifically, in addition to reductions in distress 48 and depressive symptoms 49 , participants reported improvements in self-image and self-acceptance 44 , 46 , 47 and less self-monitoring 48 after beginning gender-affirming hormone therapy. There were also indications of changes in emotional functioning, generally experienced as positive and related to greater emotional range and freedom-of-expression 46 , 48 , but sometimes noted as negative and related to mood swings and emotional imbalance 45 , 46 , 49 . Finally, improvements in interpersonal functioning and the quality of relationships were commonly reported after beginning gender-affirming hormone therapy 44 , 45 , 46 , but again these were also largely attributed to changes in satisfaction with appearance rather than direct effects of hormones 45 , 46 . While a desire for changes to appearance is a core aspect of seeking gender-affirming hormone therapy for many transgender people 7 , understanding this as a separate pathway (that is, a psychological one) can help to isolate any potential biological pathway through which hormones might affect psychosocial functioning.

Experiences on masculinizing hormone therapy

Qualitative evidence for changes in psychosocial functioning among people on masculinizing hormone therapy came from only two studies 44 , 47 . In one study 44 , participants described increased confidence and assertiveness, but also concern over increased difficulty controlling anger and reduced emotional openness. A second study 47 included participants on masculinizing hormone therapy in the overall sample and, although no quotes from these participants were specifically highlighted in the subtheme related to gender-affirming hormone therapy and sense of self, overall participants reported improvements in self-image and self-acceptance.

Quantitative review

Cross-sectional studies.

Twenty-one cross-sectional studies (46% of all studies included in this review) met the inclusion criteria for our review (see Fig. 1 for study inclusion flowchart). The total number of transgender participants across the cross-sectional studies was 37,913, with individual sample sizes ranging from 42 to 21,598 transgender participants per study. The most common method of recruitment in the cross-sectional studies was general online convenience sampling ( k  = 9; 43%), while four studies (19%) used local convenience sampling (for example, from cities and universities) and eight (38%) used hospital/clinic-based sampling. Most studies ( k  = 16; 76%) compared transgender people who were on, or had undergone, gender-affirming hormone therapy with those who had never done so, but four studies (19%) compared transgender people on gender-affirming hormone therapy with either those planning to undergo gender-affirming hormone therapy or those currently waitlisted. While 20 (95%) of these studies included assessments of well-being (the majority of studies focused on depressive symptoms), only one (5%) included a measure relevant to self-mastery and seven (33%) included measures relevant to interpersonal functioning.

Feminizing hormone therapy

Well-being . For those on feminizing hormone therapy, seven cross-sectional studies 50 , 51 , 52 , 53 , 54 , 55 , 56 demonstrated lower levels of depressive symptoms relative to controls, while one study 57 with moderate risk of bias, with a sample composed of 178 transgender women who were United States Armed Forces veterans, and one study 58 with low risk of bias, with 71 transgender women over the age of 50 recruited from a national gender identity clinic in the United Kingdom, found no significant differences—although neither of these studies included a power analysis. Additionally, one study 59 with moderate risk of bias using the 2015 US Transgender Survey, with 8,827 transgender women and 1,104 genderqueer and non-binary people assigned male at birth, showed lower levels of psychological distress for those on feminizing hormone therapy relative to controls.

While three studies 51 , 52 , 58 showed lower levels of anxiety in those on feminizing hormone therapy relative to controls, three other studies 50 , 55 , 56 showed no significant differences, although each of these studies, with moderate risk of bias, utilized different measures of anxiety and none included a power analysis.

Four studies 53 , 60 , 61 , 62 found better quality of life for those on feminizing hormone therapy, while four other studies 63 , 64 , 65 , 66 failed to confirm this effect, with three of these studies using the same outcome measure, the Short Form Health Survey (SF-36). Note, however, that two of these studies 63 , 64 , with moderate risk of bias, and conducted in Thailand by the same group, included just 44 and 60 transgender women, respectively, and no power analysis, with participants also using hormones that had not been prescribed to them or supplied by a medical professional.

The same two studies from Thailand 63 , 64 , with moderate risk of bias, reported no significant differences in optimism. Self-esteem was found to be higher for those on feminizing hormone therapy relative to controls in two studies 58 , 61 with low risk of bias.

Self-mastery . One study 51 with 208 transgender women in the United States suggested lower levels of anger for those on feminizing hormone therapy relative to controls. A moderate risk of bias was found for this study.

Interpersonal functioning . Two studies 52 , 67 reported lower levels of social anxiety for those on feminizing hormone therapy relative to controls. Another study 56 , with moderate risk of bias, found no difference in social anxiety using the same measure 67 , the three-item Social Phobia Inventory (Mini-SPIN), in an online convenience sample with 363 transfeminine people in the United States. Again, the two studies from Thailand 63 , 64 , with moderate risk of bias, suggested no significant differences in terms of social functioning. One study 58 with low risk of bias found fewer interpersonal problems among those on feminizing hormone therapy relative to controls.

Cross-sectional summary . To summarize, the most consistent evidence was found for lower levels of depressive symptoms and distress for those on femininizing hormone therapy relative to controls. While less general and social anxiety and greater quality of life are also possible, evidence is less consistent for these outcomes. This may be due to differences in measures used to assess anxiety, the source from which participants in a given study were acquiring hormones (medical professional versus unlicenced provider) and the small samples in some studies, limiting statistical power. Furthermore, evidence for outcomes such as optimism, self-esteem, anger, social functioning and interpersonal problems is limited by the fact that only few studies have examined each of these traits in transgender people undergoing feminizing hormone therapy.

Masculinizing hormone therapy

Well-being . For people on masculinizing hormone therapy, seven cross-sectional studies 52 , 54 , 55 , 56 , 61 , 68 , 69 demonstrated lower levels of depressive symptoms relative to controls. One study 57 , with moderate risk of bias, and a sample composed of 28 transgender women who were United States Armed Forces veterans, found no significant differences using the Patient Health Questionnaire-9 (PHQ-9). Additionally, one study 59 , with moderate risk of bias, using the 2015 US Transgender Survey with 7,595 transgender men and 3,711 genderqueer and non-binary people assigned female at birth, showed lower levels of psychological distress for those on masculinizing hormone therapy relative to controls.

Relatively consistently, four studies 52 , 56 , 68 , 69 demonstrated lower levels of anxiety, but one study 55 , with moderate risk of bias, with an online convenience sample in the United States with 234 transmasculine people and 49 non-binary people assigned female at birth, found no significant difference using the Depression, Anxiety and Stress Scale (DASS-21).

Results for quality of life were very mixed, with four studies 53 , 60 , 61 , 70 suggesting higher scores for those on masculinizing hormone therapy relative to controls, two studies 65 , 66 with moderate and low risk of bias finding no significant differences, and one study 64 from Thailand with moderate risk of bias showing evidence for lower quality of life—albeit in a convenience sample of 60 transgender men who were primarily using hormones that had not been prescribed to them or supplied by a medical professional.

The same study 64 from Thailand reported no significant difference in optimism. Another study 61 , with low risk of bias, demonstrated higher self-esteem for those on masculinizing hormone therapy relative to controls in a sample of 31 transmasculine people in France.

Self-mastery . No cross-sectional studies focusing on masculinizing hormone therapy included measures relevant to self-mastery.

Interpersonal functioning . Consistently, four studies 52 , 56 , 67 , 68 demonstrated lower levels of social anxiety for those on masculinizing hormone therapy relative to controls. One other study 64 suggested no significant difference in terms of social functioning. It should be noted again that this study had a moderate risk of bias and a sample of 60 transgender men primarily using hormones that had not been prescribed to them or supplied by a medical professional.

Cross-sectional summary . Taken together, the most consistent evidence is for lower levels of depressive symptoms and distress as well as general and social anxiety for those on masculinizing hormone therapy relative to controls, indicators of improvements in well-being and interpersonal functioning. Results for quality of life were mixed, with one study even demonstrating lower levels for those on masculinizing hormone therapy relative to controls—one of the few cases of lesser well-being for those on gender-affirming hormone therapy—although this may have been related to the fact that participants in this study were primarily acquiring hormones from unlicenced providers without appropriate medical guidance and supervision. While there were no cross-sectional studies assessing constructs related to self-mastery, evidence for outcomes such as optimism, self-esteem and social functioning is limited by the fact that only a single study has examined each of these traits in transgender people undergoing masculinizing hormone therapy.

Prospective cohort studies

Nineteen prospective cohort studies (41% of all studies included in this review) met the inclusion criteria for our review (see Fig. 1 for study inclusion flowchart). The total number of participants across these studies was 3,491. Sample sizes in the studies ranged from 14 to 898 participants per study. The cohorts were recruited from gender identity clinics or medical centres in Italy ( k  = 5; 26%), the Netherlands ( k  = 5; 26%), Belgium ( k  = 2; 11%), the United Kingdom ( k  = 2; 11%), the United States ( k  = 1; 5%) and Turkey ( k  = 1; 5%). Two papers (11%) used the ENIGI cohort 71 , a collaborative international study sampled from cooperating gender identity clinics in Belgium, the Netherlands, Italy and Norway. Additionally, three studies (16%) used convenience sampling in the United States, Germany/Switzerland and Australia, including online sampling. Four studies (21%) included cisgender control groups, two studies (11%) included transgender people not undergoing gender-affirming hormone therapy as controls, and one study (5%) included both types of control groups. While 18 (95%) of these studies included indicators of well-being (the majority of studies focused on depression, anxiety and psychological distress), only six (32%) included measures relevant to self-mastery (typically measures of anger), and only three (16%) included measures relevant to interpersonal functioning.

Well-being . The most consistent evidence for changes in psychosocial functioning after feminizing hormone therapy included reductions in psychological distress in four studies 72 , 73 , 74 , 75 and reductions in depressive symptoms in three studies 72 , 73 , 76 . One study 77 , with low risk of bias, a sample of 17 youth (ages 9–25 years old) on feminizing hormone therapy in the United States (with no power analysis), and follow-up at 6 and 12 months, found no statistically significant effect on change in depressive symptoms from 0 to 12 months on the Center for Epidemiologic Studies Depression Scale (CESD-R) or the PHQ-9 Modified for Teens, although the authors noted that both effect sizes were ‘notably large’ in the direction of reduced depressive symptoms. Another study 78 , with high risk of bias, with 14 people on feminizing hormone therapy in the Netherlands, and no power analysis, also found no statistically significant differences after 8 weeks on the Self-Rating Depression Scale (SDS).

For anxiety, two studies 76 , 79 conducted in the United Kingdom, with moderate risk of bias, both including power analyses, and samples of 59 and 95 people, respectively, on feminizing hormone therapy, showed no significant evidence of differences after 12 (ref. 79 ) and 18 (ref. 76 ) months on the Hospital Anxiety and Depression Scale (HADS-A). The study 78 in the Netherlands, with high risk of bias, also found no statistically significant difference after 8 weeks on the Spielberger Trait Anxiety Inventory (STAI). However, another study 72 in Italy, with moderate risk of bias, found significant reductions in anxiety after 12 months on the Self-Rating Anxiety Scale (SAS) in a sample of 78 people on feminizing hormone therapy.

Quality of life was found to be greater after feminizing hormone therapy in two studies 80 , 81 . However, the study 77 with low risk of bias, but a sample of only 17 youth on feminizing hormone therapy in the United States, and follow-up at 6 and 12 months, showed no statistically significant difference on the Pediatric Quality of Life and Enjoyment Scale (PQLES-SF); another study 82 , with moderate risk of bias and follow-up at 3 and 6 months, also found no significant difference on the Short Form Health Survey (SF-36) in a sample of 35 people on feminizing hormone therapy in Australia. Neither of these studies included a power analysis.

For affect, one study 83 , with low risk of bias, from the ENIGI cohort, found no change in negative affect but a decrease in positive affect after feminizing hormone therapy in a 3-year follow-up. The decrease in positive affect reported in this study emerged in the first 3 months and then stayed stable over repeated follow-ups over 3 years, only returning to levels statistically non-significantly different from baseline at the final time point. One study 35 , with moderate risk of bias, conducted in the Netherlands with a sample of 47 people on feminizing hormone therapy and follow-up after about 3 months, found evidence of increased affect intensity and increased emotional expressiveness, while another more recent study 75 , with low risk of bias, conducted in Italy, found reductions in alexithymia after 12 months for 24 people on feminizing hormone therapy.

One study 84 , with low risk of bias, conducted in the Netherlands with a sample of 21 youth (ages 11–27 years old) who had been on feminizing hormone therapy for at least 6 months, showed greater self-esteem.

Self-mastery . For self-mastery, three studies 35 , 78 , 85 found no significant differences in anger intensity—with the more recent study, utilizing the ENIGI cohort and a 3-year follow-up, having lower risk of bias, but none including a power analysis. However, one study 35 , with moderate risk of bias, a sample of 47 people on feminizing hormone therapy and follow-up after about 3 months showed increased anger readiness. Similarly, another study 36 , also conducted in the Netherlands in the early 1990s, with low risk of bias, but a sample of only 15 transgender women and no power analysis, with follow-up after about 3 months, showed increased anger proneness on the Anger Expression Scale (AX) and Anger Situation Questionnaire (ASQ) after feminizing hormone therapy.

One more recent study from the Netherlands 84 , with low risk of bias but no power analysis, found no significant difference in behavioural conduct problems after being on feminizing hormone therapy for at least 6 months, in a sample of 21 youth.

Interpersonal functioning . One study conducted in Italy 75 , with low risk of bias and 24 people on feminizing hormone therapy, found reductions in social anxiety after 12 months, while another study 84 , with low risk of bias and no power analysis, conducted in the Netherlands with a sample of 21 youth, found no significant differences in close friendship or social acceptance after at least 6 months on feminizing hormone therapy.

Longitudinal summary . Taken together, these prospective cohort studies suggest that feminizing hormone therapy reduces psychological distress and depressive symptoms as well as potentially improves quality of life, all indicators of improvements in well-being. For affect, one high-quality study showed potential reductions in positive affect over the course of a 3-year follow-up, but no differences in negative affect, while other studies suggested increased emotional expressiveness and affect intensity as well as reduced alexithymia. In terms of self-mastery, effects on anger were mixed, with the highest quality study finding no differences but smaller and less recent studies finding increased anger readiness and proneness after 3 months, suggesting that perhaps time course does matter to an extent, with changes evident earlier (that is, in the first 3 months of hormone therapy). Evidence for changes in interpersonal functioning came from only two studies and was inconclusive.

Well-being . As with feminizing hormone therapy, the most consistent evidence for changes in psychosocial functioning after masculinizing hormone therapy involved reductions in psychological distress in five studies 72 , 73 , 74 , 75 , 86 and depressive symptoms in three (refs. 72 , 73 , 76 ). Similar to feminizing hormone therapy, the same study 77 , from the United States, with low risk of bias, found no statistically significant effect of masculinizing hormone therapy on depressive symptoms in a sample of 33 youth from 0 to 12 months’ follow-up on the CESD-R or PHQ-9 Modified for Teens, with the same caveat that both effect sizes were ‘notably large’ in the direction of reduced depressive symptoms.

For anxiety, two studies 76 , 79 in the United Kingdom, with moderate risk of bias, showed no significant evidence of differences after 12 (ref. 79 ) and 18 (ref. 76 ) months on the Hospital Anxiety and Depression Scale (HADS-A), but both included power analyses reporting adequate statistical power, with samples of 59 and 83 people on masculinizing hormone therapy, respectively. However, one study 72 , with moderate risk of bias, found significant reductions in anxiety after 12 months on the SAS in a sample of 29 people on masculinizing hormone therapy in Italy.

Two studies 80 , 82 reported greater quality of life for those on masculinizing hormone therapy after 3 (refs. 80 , 82 ) and 6 (ref. 82 ) months, but two other studies 77 , 81 found no significant differences: one study 77 , with low risk of bias, a sample of 33 youth on masculinizing hormone therapy, in the United States and follow-up at 6 and 12 months, showed no statistically significant difference on the Pediatric Quality of Life and Enjoyment Scale (PQLES-SF); and another study 81 , with moderate risk of bias, a sample of 27 people on masculinizing hormone therapy, in Italy and follow-up at 12 months, showed no statistically significant difference on the World Health Organization Quality of Life Questionnaire (WHOQOL-100); neither study included a power analysis.

Interestingly, measures of affect showed evidence of affective dampening after masculinizing hormone therapy, including less positive and negative affect in the ENIGI cohort 83 , as well as less affect intensity, but not a significant difference in emotional expressiveness, in one study 35 , with moderate risk of bias, conducted in the Netherlands with 54 people on masculinizing hormone therapy and follow-up after 14 weeks. One study 87 , with moderate risk of bias, conducted in Germany and Switzerland, with 23 people on masculinizing hormone therapy and follow-up at 3 and 6 months, found reductions in neuroticism, while another study 75 , with low risk of bias conducted in Italy, found reductions in alexithymia after 12 months for 38 people on masculinizing hormone therapy.

One study 84 , with low risk of bias, conducted in the Netherlands with a sample of 49 youths, showed greater self-esteem after at least 6 months on masculinizing hormone therapy.

Self-mastery . Three studies 35 , 36 , 88 showed increases in anger expression 88 , anger readiness 35 and anger proneness 36 , all within 3–7 months of commencing masculinizing hormone therapy. However, two studies 35 , 85 found no significant differences in anger intensity after masculinizing hormone therapy, including in the ENIGI cohort 85 (although this study did report a trend toward increased anger intensity only after 3 months, but not at any other follow-up out to 36 months, in those on masculinizing hormone therapy).

Another study 84 , from the Netherlands, with low risk of bias, found fewer behavioural conduct problems after at least 6 months on masculinizing hormone therapy in a sample of 49 youths.

Interpersonal functioning . For interpersonal functioning, one study 75 , with low risk of bias, with 38 people on masculinizing hormone therapy, conducted in Italy, found reductions in social anxiety after 12 months, while another study 87 , with moderate risk of bias, conducted in Germany and Switzerland, with 23 people on masculinizing hormone therapy, found increases in extraversion and agreeableness after 3 and 6 months of follow-up.

One study 84 , with low risk of bias, conducted in the Netherlands, found no significant differences in close friendship or social acceptance after at least 6 months in a sample of 49 youth on masculinizing hormone therapy, again with no power analysis.

Longitudinal summary. Taken together, these prospective cohort studies tended to show that masculinizing hormone therapy reduced psychological distress and depressive symptoms. Effects on anxiety and quality of life were mixed. Notably, some studies suggested a dampening in affective experiences after masculinizing hormone therapy, although it is unclear whether this might indicate improvements or decrements in well-being given that this encompassed dampening of indicators of both positive and negative affect. For self-mastery, some studies indicated increased anger readiness and expression as well as proneness to anger, potential indicators of decrements in self-mastery, although this was not confirmed by increased anger intensity, suggesting that the emotion itself might not be affected, but rather the willingness to show/express it. Limited evidence on interpersonal functioning suggested improvements here too.

Adjustment for potential confounders

Cross-sectional studies provide limited evidence for changes in psychosocial functioning after gender-affirming hormone therapy due to a lack of comparison of outcomes across time, which is required to reflect change. Prospective cohort studies are the gold-standard in terms of evidence for change; however, these studies are also vulnerable to risk of bias due to confounding factors. This is particularly important in this case because as people undergo gender transition, many physical and social changes occur that can, by themselves, explain the results discussed in this review. Despite pre-/post-hormone therapy designs, prospective cohort studies showed substantial risk of bias related to confounding. For example, gender transition can markedly improve body image, which by itself can improve psychosocial functioning 89 . At the same time, for some people transitioning is accompanied by a substantial amount of exposure to stigma, and even aggression, thereby negatively affecting at least some indicators of well-being (for example, anxiety) or interpersonal functioning (for example, social phobia).

Table 1 lists the various potential confounders adjusted for across the included studies. Notably, measures of body image and gender-affirming surgeries were most commonly included, but these critical confounders were still only adjusted for in about one-third of the quantitative studies. Other potentially critical confounders, such as gender affirmation by others and social stigma 90 , were only adjusted for in two studies each. Given these limited attempts to adjust quantitative estimates for plausible, or even known, confounders, the extant quantitative literature cannot be conclusive in terms of biological versus psychological or sociocultural pathways by which gender-affirming hormone therapy might influence psychosocial outcomes. This remains a substantial limitation of this body of work.

The current systematic review highlights the state of the science concerning the potential effects of gender-affirming hormone therapy on psychosocial functioning for transgender people (see Fig. 2 for a summary of the main findings of the review). The most consistent evidence across qualitative and quantitative studies, both cross-sectional and prospective cohorts, is that gender-affirming hormone therapy reduces depressive symptoms and psychological distress, consistent with results of previous systematic reviews 37 , 38 , 39 , 40 . There was also some evidence of potential reduction in general anxiety among those on masculinizing hormone therapy; however, this was primarily demonstrated in cross-sectional studies and not yet substantiated in prospective cohort designs. Notably, these changes all reflect reductions in distress rather than direct increases in positive states, suggesting that gender-affirming hormones may improve well-being primarily by helping to eliminate gender dysphoria, whether through improved body image or other relevant pathways, or even simply increasing an individual’s sense of control and autonomy over one’s body and gender expression.

Stronger and weaker evidence for psychosocial effects of gender-affirming hormone therapy is summarized for those on feminizing and masculinizing hormone therapy separately. Chemical symbols represent oestradiol (top) and spironolactone (bottom) for a common approach to feminizing hormone therapy, and testosterone for a common approach to masculinizing hormone therapy. Figure created with BioRender.com .

Evidence for effects of hormone therapy on quality of life and affect in the current review is inconsistent, but tends to point in the direction of improvements. However, there was some quantitative evidence of affective dampening among those on masculinizing hormone therapy, which may be related to the restricted range of emotions described by participants on masculinizing hormone therapy in qualitative work. Relatedly, in the current review we found that participants on feminizing hormone therapy sometimes described mood swings and emotional imbalances, but also gave greater insight into their emotions and increased emotional expressiveness. Evidence from an ad hoc questionnaire of side-effects included in the ENIGI cohort 91 , 92 further substantiates these differences in emotionality between those on masculinizing and feminizing hormone therapy. Given these suggestive results, future research should continue to probe the duration of any potential changes in emotionality and whether they are experienced as distressing, or even pleasing, by transgender people at any point in time.

Self-mastery was the aspect of psychosocial functioning with the most inconclusive results in the current review. We found that earlier studies, conducted in the 1990s and early 2000s, hinted at decreased self-mastery in the form of greater readiness to act on anger, both for those on masculinizing and feminizing hormone therapy. This was also confirmed in a more recent study with people on masculinizing hormone therapy showing greater anger expression 88 , but not examined recently in those on feminizing hormone therapy. However, anger intensity does not seem to increase for those on either masculinizing or feminizing hormone therapy. These results are consistent with a recent systematic review of effects of testosterone therapy on aggression in transgender men 93 . Importantly, while self-mastery goes beyond anger expression, no studies have examined other elements of self-mastery, such as self-control or impulsivity, with only one study 84 investigating behavioural conduct in transgender youth. This remains an important avenue for future investigation.

Evidence from the current review for improvements in the domain of interpersonal functioning is limited and inconclusive, but hints toward positive change, particularly for those on masculinizing hormone therapy, most commonly in the form of reduced social anxiety. Given the dearth of research on interpersonal functioning in prospective cohort studies, future longitudinal research on gender-affirming hormone therapy should aim to include relevant measures, such as measures of loneliness (for example, UCLA Loneliness Scale), trust (for example, Rempel and Holmes Trust Scale), attachment styles (for example, Experiences in Close Relationships Scale), relationship satisfaction (for example, Couples Satisfaction Index) and other forms of social functioning.

Notably, the juxtaposition of increased anger readiness and decreased social anxiety specifically for those on masculinizing hormone therapy is interesting in that it may point toward a causal role for testosterone in these changes. On average, cisgender women show lower rates of aggression 94 and higher rates of social anxiety 95 relative to cisgender men. This inversion of traits could therefore be driven in part by the effects of testosterone, pushing those on masculinizing hormone therapy toward more assertive and self-confident behaviour in social interactions 96 , 97 . Future work is necessary to confirm this possibility and attempt to parse biological and sociocultural pathways.

It is interesting to note that these changes, along with others, might also reflect endorsement of gendered stereotypes pertaining to psychosocial functioning. For example, the affective dampening reported in some studies among participants on masculinizing hormone therapy is in line with gender role expectations that men should not experience or express ‘too much’ emotion, while greater anger expression could be related to the fact that this specific emotion is an exception to, and reversal of, this norm 98 . Among participants on feminizing hormone therapy, reports of mood swings and emotional imbalances may be in line with core stereotypes of women 99 . If these changes, identified on self-report measures, do actually reflect gender-stereotyped expectations on the part of participants rather than objective changes in psychosocial functioning, other types of tasks that do not rely on self-report exclusively (for example, behavioural tasks) may prove useful in unpacking these preliminary findings.

Across all outcomes, consideration of study quality, measures, sample size and other factors is necessary. Generally, studies were at risk of bias due to confounding and many included small samples, with consequent low statistical power, to detect changes in psychosocial functioning, along with frequent lack of correction for multiple tests to reduce family-wise error rates. Furthermore, while the variety of measures used in the literature is in some ways a strength (that is, in terms of generalizability of effects), it is difficult to compare inconsistent results across studies when they may be a product of the specific measures, or operationalizations, used in each study.

In quantitative studies, including cross-sectional and prospective cohort studies, there is a need for research with adequate control groups, potentially composed of matched cisgender people as well as transgender people not wishing to undergo gender-affirming hormone therapy, as well as those waitlisted for treatment 100 . Identifying appropriate control groups is no easy task, given that these might differ depending on the outcome examined. For example, transgender people waiting for hormone therapy might be particularly distressed because they feel that what they need is still far away. So, with regard to well-being, perhaps people who do not want hormone therapy are a better comparison. However, it is of course possible that there are already differences in psychosocial functioning between people who do and do not seek hormone therapy to affirm their gender, meaning that studies utilizing both types of control groups and following changes in each over time may be most appropriate.

One important issue that has not been systematically considered in the literature on gender-affirming hormone therapy is the importance of timing. Findings from the current review point toward a potentially critical role of time course in shaping effects on various facets of psychosocial functioning (for example, there is some evidence from the current review, as well as another recent review 93 , that increases in anger expression among those on masculinizing hormone therapy may be short-lived, appearing only in the first 3–6 months after beginning hormone therapy and then reducing to baseline levels over time). Relatedly, physical changes resulting from gender-affirming hormone therapy can vary in onset and duration; for example, for those on feminizing hormone therapy, breast development may begin at about 3 months but only reach desired levels after about 3 years 101 . It is also unclear whether specific psychosocial changes may reverse if gender-affirming hormone therapy is ceased 102 . Developmental timing is also a critical consideration, particularly for transgender children and adolescents, for whom puberty may induce changes that are more difficult to modify later in life or are even irreversible 103 . Future research examining the effects of hormone therapy on psychosocial outcomes needs to explicitly take time into account in all of these different ways.

Furthermore, in all of these studies, participants were transgender people who volunteered to participate in a study, so results might depend on how the study’s aims were introduced to them in interaction with the agenda they might have wanted to push forward. For example, studies stating their goals were to examine effects of hormone therapy might have attracted participants who wanted to demonstrate its benefits (which, in addition, may have been understood to be better demonstrated by expressing gender stereotypical affective responses, for example), whereas studies claiming their aim was on understanding well-being among transgender people might have attracted more participants who wanted to voice negative experiences. These details might in fact explain some of the contradictions found and point to the need to consider these more psychosocial aspects of transition with greater care when conducting this kind of research.

In addition, without a better understanding of what transgender people wish to achieve with their transition, it is hard to know exactly whether a particular change is positive or negative. For example, increases in anger in those on masculinizing hormone therapy might at first seem negative, but they might be experienced positively if the person in question sees this as confirming their masculinity. At the same time, outcomes need to be understood by reference to what transgender people think medical providers wish to achieve, or even what medical providers tell them about desirable or expected effects. Given the authority of medical providers to determine treatment courses, some transgender people might wish to report effects that are in line with what is expected by providers (again, potentially gender stereotypical responses) so as to ensure the continuation of treatment. Alternatively, people might have been given expectations that are thwarted and low well-being might refer more to disappointment than to biological effects of hormones.

An important starting point in understanding potential psychosocial implications of gender-affirming hormone therapy is indeed to listen to the voices and experiences of transgender people. There have been calls among scholars to prioritize empowerment of transgender people and communities in relevant research, especially by including their voices throughout the research process 104 . Despite the importance of this area of research and the logic of querying transgender people’s lived experiences as they relate to gender-affirming hormone usage, very few studies have been conducted on this topic. Furthermore, only two of the six studies identified here included people on masculinizing hormone therapy in the sample. Therefore, the voices of transmasculine people, as well as experiences on masculinizing hormones, are almost entirely absent from the literature.

While the aim of the current review was to assess the evidence for changes in psychosocial functioning following gender-affirming hormone therapy, this topic may be inherently linked to potential changes in cognitive functioning as well. Other recent systematic reviews 40 , 105 have hinted at a link between gender-affirming hormone therapy and cognitive functioning changes, including improved visuospatial ability among those on masculinizing hormone therapy. Such cognitive changes, potentially driven by changes in brain structure or function 29 , 106 , may overlap with how the brain processes social and emotional stimuli, influencing psychosocial functioning for transgender people after gender-affirming hormone therapy. Furthermore, where cognitive changes align with gender stereotypes, they may be felt to confirm successful gender transition and, thereby, enhance well-being.

There is evidence that gender-affirming hormone therapy results in improved psychosocial functioning for transgender people, primarily improved well-being. Changes in self-mastery and interpersonal functioning are more ambiguous—with patterns across these dimensions that may diverge for those on masculinizing versus feminizing hormone therapies. Given the paramount importance of social relationships to health 20 , 21 , further high-quality evidence for psychosocial effects of gender-affirming hormone therapy (for example, on self-mastery and interpersonal functioning) is vital to ensuring health equity for transgender people. Attempts to limit access to gender-affirming care, including hormone therapy, have sometimes relied on a lack of scientific evidence for various outcomes 41 , 42 , but the current review points toward improvements in overall well-being, particularly in the form of reduced distress, implying that any potential risks to other facets of psychosocial functioning, which are likely limited, are outweighed by the benefits of these vital treatments for transgender health. Continuing carefully conducted and executed research on this topic will be essential to mitigating any potential risks and promoting transgender health across countries in future.

Eligibility criteria

All empirical research published or in press by May 2022 was considered for inclusion in the current systematic review. To be deemed eligible, research needed to (1) include transgender participants who had previously used or were currently using gender-affirming hormone therapy (not including studies focused exclusively on puberty suppression without further gender-affirming hormone therapy); (2) evaluate at least one psychosocial outcome as broadly defined in the introduction—when multiple relevant outcomes were presented, all were included, but we chose to include total scale scores over subscales when both were presented separately in one paper; (3) encompass normal levels of functioning—that is, we chose not to include studies that examined changes in clinical psychiatric diagnoses; (4) for quantitative research, provide a relevant comparison either within-person before and after gender-affirming hormone therapy, or between-person comparing transgender people who had previously or were currently using gender-affirming hormone therapy to transgender people who had not yet used gender-affirming hormone therapy, or who were on a waitlist to receive gender-affirming hormone therapy; (5) for quantitative research, include psychometrically validated quantitative measures rather than ad hoc self-reports of symptoms or review of medical chart notes—although we chose to exclude studies utilizing the Minnesota Multiphasic Personality Inventory or similar measures involving sex norms, as interpretation of these sex-standardized scales is problematic in transgender samples given that the sex norms have been validated with exclusively cisgender samples; 107 and (6) for qualitative research, include a formal and systematic thematic analysis rather than a cursory description of observations from text.

Search strategy and study selection

We followed PRISMA guidelines when carrying out the search strategy for this review 108 . Key terms (hormones, hormone replacement therapy, testosterone replacement therapy, oestrogen replacement therapy, gender affirmation, gender-affirming, health, well-being, psychosocial functioning, transgender, non-binary, gender diverse, gender fluid, transmasculine, transfeminine, transsexual) were identified from a number of articles 37 , 39 , 40 , 109 , 110 on the topic along with MeSH terms. PubMed, PsycNet and Web of Science databases were searched between the years 1980 and 2022. This time period was selected due to the relative recency of papers that explore this topic as highlighted in similar prior reviews, where the dates of individual papers did not stretch past 40 years before the search despite the wider date range employed 50 , 110 . We chose to restrict our search to the published academic literature as (1) critics of gender-affirming hormone therapy have relied on arguments for lack of consensus in the published academic literature to attempt to restrict healthcare access for transgender people, therefore a comprehensive and systematic review of this work is necessary to adjudicate such claims and (2) differences in the types of grey literature available (that is, more cross-sectional studies relative to prospective cohorts) could lead to biases in the conclusions drawn between these different sections of the review. Terms for transgender people (for example, transgender, non-binary, gender diverse, gender fluid, transmasculine, transfeminine, transsexual and gender dysphoria) were searched using the OR function and were combined with terms related to psychosocial outcomes (for example, mood, anxiety, depression, self-esteem), as well as hormone usage (for example, hormones, cross sex hormone therapy, testosterone replacement therapy, feminizing, masculinizing)—(see Supplementary Tables 3 and 4 for tables containing search history and final search terms). Additionally, the reference lists of selected articles as well as the ‘similar readings’ function in PubMed were searched to identify any further possible relevant papers (see Fig. 1 for the study inclusion flowchart and Supplementary Table 5 for a description of all studies included in the review).

Data availability

No specific datasets were generated for the current systematic review. A table containing coding of risk-of-bias for all studies in the current review can be found in the Supplementary Information .

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This study was funded by the European Union (ERC-StG 101042028 to D.M.D.). Views and opinions expressed are, however, those of the authors only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible for them. The funders had no role in the research design, decision to publish or preparation of the manuscript.

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D.M.D. conceptualized the research. D.M.D. and T.O.G.L. performed the systematic review. T.O.G.L. coded studies with supervision from D.M.D. and M.B. All authors drafted and reviewed the final manuscript.

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Doyle, D.M., Lewis, T.O.G. & Barreto, M. A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people. Nat Hum Behav 7 , 1320–1331 (2023). https://doi.org/10.1038/s41562-023-01605-w

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Gender Affirming Therapy for Gender Dysphoria: A Rapid Qualitative Review [Internet]

• PMID: 33231964
• Bookshelf ID: NBK564233

Transgender, non-binary, and genderqueer people face high levels of discrimination, stigma and violence. Recent surveys indicate that transgender people represent approximately 0.5% of the population, and this number is expected to grow as people feel more comfortable expressing their gender identity. In the political sphere, recent federal legislation has granted protection against the discrimination of transgender people in Canada.

Transgender individuals comprise a diverse group with specific and varied social, medical and psychological needs. Transgender people can experience high rates of distress and suicidality. , Almost half (43%) of transgender people have a history of attempting suicide. Suicide risk is highest when experiencing transphobia and when waiting to transition. , Rates of suicidality can drop markedly once transition has been completed. Some transgender individuals choose hormone therapy or gender reassignment surgery. Currently, candidates for hormone therapy must demonstrate a consistent and persistent gender-variant identity that meets criteria for gender dysphoria as categorized by the DSM-5.

Within the health care setting, transgender people have been underserved and often experience discrimination. This is may be due to the absence of training about transgender health in health professional education. Historically, transgender people’s needs for hormone therapy were served exclusively by endocrinologists. More recently there has been a shift in the duty of responsibility toward community physicians.

Given the historical context of marginalization of this community, their diverse health needs, and the shift of medical care from specialists to primary care physicians, it is important to examine the experiences of transgender individuals within the current Canadian context and to explore the experiences of the health care providers who treat them.

Copyright © 2020 Canadian Agency for Drugs and Technologies in Health.

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The Gender Reassignment Controversy

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

Posted March 16, 2018 | Reviewed by Ekua Hagan

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

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

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

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

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

The Money Perspective

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

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

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

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

Adult Reassignment Surgery Motivation

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

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

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

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

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

Adult Reassignment Results

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

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

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

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

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

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

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

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

Aspirational Surgery

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

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

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

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

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

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

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

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

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Opinion A new report roils the debate on youth gender care

Paul Garcia-Ryan is the board president of Therapy First.

A comprehensive review commissioned by England’s National Health Service, released last week, found that gender transition medical treatment for children and young people has been built on “shaky foundations,” with “remarkably weak” evidence. The independent study — led by physician Hilary Cass , the former president of the Royal College of Paediatrics and Child Health — incorporates multiple systematic reviews “to provide the best available collation of published evidence,” as well as interviews with clinicians, parents and young people, in reaching its conclusions.

Referring to young people who have already been treated under these dubious circumstances, such as those at the Tavistock Centre’s now-closed Gender Identity Development Service , Cass wrote, “They deserve very much better.”

In the wake of the Cass Review’s release — which has rocked the British medical and media establishment, and might soon reverberate in the United States — many are asking how we got here. How did clinicians come to recommend the use of puberty blockers and cross-sex hormones to thousands of children and adolescents when there was insufficient evidence that these treatments were safe and effective?

Part of the reason is that “the toxicity of the debate is exceptional,” as Cass notes in her foreword: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”

I know all too well how the absence of good-faith, healthy debate on this subject can affect clinicians and patients. When I was 15, a therapist affirmed my conviction that I was born in the wrong body. After more than a decade of hormonal and surgical interventions, I detransitioned at age 30. I had come to realize that my transition was motivated by my difficulty reconciling with being gay. Today, I am a licensed clinical social worker and board president of Therapy First, formerly the Gender Exploratory Therapy Association, a nonprofit organization that advocates psychotherapy as a first-line treatment for youth gender dysphoria.

Usually in psychotherapy, treatment approaches are refined and improved by vigorous discussion, research and dissemination of new information. When it comes to youth gender treatments, though, professionals who raise concerns have been censored and subjected to reputational damage, threats to their license and doxing. As a result, countless gender nonconforming young people have been badly served.

Therapy First has been the target of silencing and intimidation efforts. Now with a professional membership of more than 300 clinicians based in 36 states and 14 countries, we are joined in our concern regarding the quality of mental health care provided to gender dysphoric youth. Even though the organization is apolitical and non-religious, with many of our members being LGBT, we have been falsely linked to the religious right . Despite being strongly opposed to conversion therapy, or trying to change someone’s sexual orientation or gender identity, we have been accused of practicing it.

What I’ve learned is that therapists who cite the poor quality of evidence in support of medical interventions for youth gender dysphoria, or who advocate traditional principles of psychotherapy in this area, are likely to be vilified — sometimes by fellow clinicians. Last week alone, eight complaints were filed against one of our members’ licenses by other therapists for simply posting, on a professional Listserv, the link to one of our organization’s webinars, on trauma-informed mind-body practices.

An activist website has labeled our therapists as part of the “global anti-transgender movement” and listed details from their personal lives, including the names of their children and other family members. Last month in London, the Telegraph reported , a medical conference that explored evidence and heard from seasoned therapists and doctors regarding the treatment of gender dysphoria was interrupted by masked protesters who set off a smoke bomb and attempted to force their way into the building.

In addition to worrying about activists outside the consulting room, therapists apparently must now also be concerned about whether their patients are wielding hidden cameras. This month, an undercover video recording of a therapy session was posted online, presenting the clinician as a practitioner of conversion therapy, yet the would-be video sting merely revealed a clinician engaged in normal therapeutic exploration. In the current climate, any therapeutic response other than immediate affirmation is considered transphobic.

It isn’t right that professionals must risk their livelihood and reputation to help young people struggling with gender dysphoria. If the culture of bullying persists, I fear that fewer clinicians with a developmental approach will be inclined to keep working with this population. These young people will be left with clinicians who aren’t following the science, many with good intentions, but others who might behave more like activists than mental health professionals.

The Cass Review made clear that the evidence supporting medical interventions in youth gender dysphoria is utterly insufficient, and that alternative approaches, such as psychotherapy, need to be encouraged. Only then will gender-questioning youth be able to get the help they need to navigate their distress.

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Youth Gender Medications Limited in England, Part of Big Shift in Europe

Five European countries have recently restricted hormone treatments for adolescents with gender distress. They have not banned the care, unlike many U.S. states.

By Azeen Ghorayshi

Azeen Ghorayshi reports on transgender health and visited the world’s first youth gender clinic in Amsterdam this fall.

The National Health Service in England started restricting gender treatments for children this month, making it the fifth European country to limit the medications because of a lack of evidence of their benefits and concern about long-term harms.

England’s change resulted from a four-year review released Tuesday evening by Dr. Hilary Cass, an independent pediatrician. “For most young people, a medical pathway will not be the best way to manage their gender-related distress,” the report concluded. In a related editorial published in a medical journal, Dr. Cass said the evidence that youth gender treatments were beneficial was “built on shaky foundations.”

The N.H.S. will no longer offer drugs that block puberty , except for patients enrolled in clinical research. And the report recommended that hormones like testosterone and estrogen, which spur permanent physical changes, be prescribed to minors with “extreme caution.” (The guidelines do not apply to doctors in private practice, who serve a small fraction of the population.)

England’s move is part of a broader shift in northern Europe, where health officials have been concerned by soaring demand for adolescent gender treatments in recent years. Many patients also have mental health conditions that make it difficult to pinpoint the root cause of their distress, known as dysphoria.

In 2020, Finland’s health agency restricted the care by recommending psychotherapy as the primary treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments to “exceptional cases.”

In December, regional health authorities in Norway designated youth gender medicine as a “treatment under trial,” meaning hormones will be prescribed only to adolescents in clinical trials. And in Denmark, new guidelines being finalized this year will limit hormone treatments to transgender adolescents who have experienced dysphoria since early childhood.

Several transgender advocacy groups in Europe have condemned the changes , saying that they infringe on civil rights and exacerbate the problems of overstretched health systems. In England, around 5,800 children were on the waiting list for gender services at the end of 2023, according to the N.H.S.

“The waiting list is known to be hell,” said N., a 17-year-old transgender boy in southern England who requested to withhold his full name for privacy. He has been on the waiting list for five years, during which time he was diagnosed with autism and depression. “On top of the trans panic our own government is pushing, we feel forgotten and left behind,” he said.

In the United States, Republican politicians have cited the pullback in Europe to justify laws against youth gender medicine. But the European policies are notably different from the outright bans for adolescents passed in 22 U.S. states, some of which threaten doctors with prison time or investigate parents for child abuse. The European countries will still allow gender treatments for certain adolescents and are requiring new clinical trials to study and better understand their effects.

“We haven’t banned the treatment,” said Dr. Mette Ewers Haahr, a psychiatrist who leads Denmark’s sole youth gender clinic, in Copenhagen. Effective treatments must consider human rights and patient safety, she said. “You have to weigh both.”

In February, the European Academy of Paediatrics acknowledged the concerns about youth gender medicine. “The fundamental question of whether biomedical treatments (including hormone therapy) for gender dysphoria are effective remains contested,” the group wrote. In contrast, the American Academy of Pediatrics last summer reaffirmed its endorsement of the care, stating that hormonal treatments are essential and should be covered by health insurers, while also commissioning a systematic review of evidence.

Europeans pioneered the use of gender treatments for young people. In the 1990s, a clinic in Amsterdam began giving puberty-suppressing drugs to adolescents who had felt they were a different gender since early childhood.

The Dutch doctors reasoned that puberty blockers could give young patients with gender dysphoria time to explore their identity and decide whether to proceed with hormones to ultimately transition. For patients facing male puberty, the drugs would stave off the physical changes — such as a deeper voice and facial hair — that could make it more difficult for them to live as women in adulthood. The Dutch team’s research, which was first published in 2011 and tracked a carefully selected group of 70 adolescents, found that puberty blockers, in conjunction with therapy, improved psychological functioning.

That study was hugely influential, inspiring clinics around the world to follow the Dutch protocol. Referrals to these clinics began to surge around 2014, though the numbers remain small. At Sweden’s clinic, for example, referrals grew to 350 adolescents in 2022 from around 50 in 2014. In England, those numbers grew to 3,600 referrals in 2022 from 470 in 2014.

Clinics worldwide reported that the increase was largely driven by patients raised as girls. And unlike the participants in the original Dutch study, many of the new patients did not experience gender distress until puberty and had other mental health conditions, including depression and autism.

Given these changes, some clinicians are questioning the relevance of the original Dutch findings for today’s patients.

“The whole world is giving the treatment, to thousands, tens of thousands of young people, based on one study,” said Dr. Riittakerttu Kaltiala, a psychiatrist who has led the youth gender program in Finland since 2011 and has become a vocal critic of the care.

Dr. Kaltiala’s own research found that about 80 percent of patients at the Finnish clinic were born female and began experiencing gender distress later in adolescence. Many patients also had psychological issues and were not helped by hormonal treatments, she found. In 2020, Finland severely limited use of the drugs.

Around the same time, the Swedish government commissioned a rigorous research review that found “insufficient” evidence for hormone therapies for youth. In 2022, Sweden recommended hormones only for “exceptional cases,” citing in part the uncertainty around how many young people may choose to stop or reverse their medical transitions down the line, known as detransitioning.

Even the original Dutch clinic is facing pressure to limit patients receiving the care. In December, a public documentary series in the Netherlands questioned the basis of the treatments. And in February, months after a far-right political party swept an election in a country long known as socially liberal , the Dutch Parliament passed a resolution to conduct research comparing the current Dutch approach with that of other European countries.

“I would have liked that the Netherlands was an island,” said Dr. Annelou de Vries, a psychiatrist who led the original Dutch research and still heads the Amsterdam clinic. “But of course, we are not — we are also part of the global world. So in a way, if everybody is starting to be concerned, of course, these concerns come also to our country.”

In England, brewing concerns about the surge of new patients reached a boiling point in 2018, when 10 clinicians at the N.H.S.’s sole youth gender clinic, known as the Tavistock Gender Identity Development Service, formally complained that they felt pressure to quickly approve children, including those with serious mental health problems, for puberty blockers.

In 2021, Tavistock clinicians published a study of 44 children who took puberty blockers that showed a different result from the Dutch: The patients given the drugs, on average, saw no impact on psychological function.

Although the drugs did not lessen thoughts of self-harm or the severity of dysphoria, the adolescents were “resoundingly thrilled to be on the blocker,” Dr. Polly Carmichael, the head of the clinic, said at a 2016 conference . And 43 of the 44 study participants later chose to start testosterone or estrogen, raising questions about whether the drug was serving its intended purpose of giving adolescents time to consider whether a medical transition was right for them.

In 2020, the N.H.S. commissioned Dr. Cass to carry out an independent review of the treatments. She commissioned scientific reviews and considered international guidelines of the care. She also met with young people and their families, trans adults, people who had detransitioned, advocacy groups and clinicians.

The review concluded that the N.H.S.’s standard of care was inadequate, with long waiting lists for access to drug treatments and few routes to address the mental health concerns that may be contributing to gender distress. The N.H.S. shuttered the Tavistock center last month and opened two new youth gender clinics, which Dr. Cass said should have a “holistic” approach, with more support for those with autism, depression and eating disorders, as well as psychotherapy to help adolescents explore their identities.

“Children and young people have just been really poorly served,” Dr. Cass said in an interview with the editor of The British Medical Journal, released Tuesday. She added, “I can’t think of another area of pediatric care where we give young people potentially irreversible treatments and have no idea what happens to them in adulthood.”

The changes enacted by the N.H.S. this month are “an acknowledgment that our concerns were, in fact, valid,” said Anna Hutchinson, a clinical psychologist in London who was one of the Tavistock staff members who raised concerns in 2018. “It’s reassuring that we’re going to return to a more robust, evidence-based pathway for decisions relating to these children.”

Some critics said that Europe, like the United States, had also been influenced by a growing backlash against transgender people.

In Britain, for example, a yearslong fight over a proposed law that would have made it easier for transgender people to change the gender on their identification documents galvanized a political movement to try to exclude transgender women from women’s sports, prisons and domestic violence shelters.

“The intention with the Cass review is to be neutral, but I think that neutral has maybe moved,” said Laurence Webb, a representative from Mermaids, a trans youth advocacy organization in Britain. “Extremist views have become much more normalized.”

Other countries have seen more overt attacks on transgender rights and health care. In 2020, Hungary’s Parliament passed a law banning gender identity changes on legal documents. Last year, Russia banned legal gender changes as well as gender-related medical care, with one lawmaker describing gender surgeries as the “path to the degeneration of the nation.”

In France this year, a group of conservative legislators introduced a bill to ban doctors from prescribing puberty blockers and hormones, with punishments of two years’ imprisonment and a fine of 30,000 euros, or about $32,600. And on Monday, the Vatican condemned gender transitions as threats to human dignity.

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes.

M Hassan Murad , MB Elamin , M Zumaeta Garcia , RJ Mullan , A Murad , PJ Erwin , and VM Montori .

Review published: 2010 .

• CRD summary

The authors concluded that very low quality evidence suggested that hormonal interventions in individuals undergoing sex reassignment were likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life. This conclusion reflects the evidence but methodological limitations related to individual studies and the review synthesis suggest that it should not be considered reliable.

• Authors' objectives

To evaluate the effects of hormonal therapy on quality of life and other psychosocial outcomes in individuals undergoing sex reassignment.

Five databases (including MEDLINE, EMBASE and PsycINFO) were searched from 1966 to February 2008. No language restrictions were imposed. Search terms were reported. Further studies were identified through reference lists of included articles and content experts.

• Study selection

All studies (except single case reports) that investigated the use of endocrine interventions as part of sex reassignment in male-to-female or female-to-male individuals with gender identity disorder were eligible for inclusion. The outcomes of interest were quality of life and other psychosocial outcomes (as defined in the review). Studies with a follow-up period of less than three months were excluded.

The included studies were published between 1971 and 2007. The mean age of male-to-female participants was 38 years. The mean age of female-to-male participants was 31 years. Most studies were reportedly performed in Europe; single studies were performed in Canada and Singapore. Where reported, hormone therapies and treatment durations varied across the studies. Exposure to hormone therapy was self-reported in most studies. Outcomes were measured using structured interviews, clinical exams, questionnaires and a website.

Two reviewers independently selected the studies for inclusion; any disagreements were resolved by discussion, with involvement of a third reviewer where necessary.

• Assessment of study quality

The strength of the evidence was assessed using the GRADE approach. Multiple reviewers undertook the GRADE assessments; any disagreements were resolved through consensus or arbitration.

• Data extraction

Data on the outcomes were extracted by two independent reviewers to enable calculation of odds ratios with 95% confidence intervals (controlled studies only) or proportions (uncontrolled studies).

• Methods of synthesis

Odds ratios (with 95% confidence intervals) and proportions from individual studies were pooled using random-effects meta-analysis. Statistical heterogeneity was assessed using the Ι² statistic. Subgroup analyses were performed for male-to-female and female-to-male populations.

• Results of the review

Twenty-eight observational studies were included in the review (1,833 participants). It was unclear whether three or four studies included a control group; the other studies did not. Across the studies (where reported), length of follow-up (or time between sex reassignment and study with cross-sectional studies) ranged from two months to 16 years. None of the studies were randomised. Drop-out rates (where reported) ranged from zero to 75%. The overall quality of the evidence was very low.

Following sex reassignment, most participants reported statistically significant improvements in gender dysphoria (80%, 95% CI 68 to 89; eight studies; Ι²=82%), psychological symptoms (78%, 95% CI 56 to 94; seven studies; Ι²=86%), quality of life (80%, 95% CI 72 to 88; 16 studies; Ι²=78%) and sexual function (72%, 95% CI 60 to 81; 15 studies; Ι²=78%).

Further results were reported in the paper.

• Authors' conclusions

Very low quality evidence suggested that hormonal interventions in individuals undergoing sex reassignment were likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

• CRD commentary

The review question was clear and supported by broad inclusion criteria. Relevant databases were searched and no language restrictions were imposed. Efforts were made throughout the review process to minimise reviewer error and bias. The overall strength of the evidence was assessed using a suitable well-known tool; results showed that the evidence was of very low quality. Study details were presented.

The statistical methods of synthesis did not seem appropriate given the substantial heterogeneity shown between the studies. The authors acknowledged the risk of reporting bias within the studies. They stated that inferences regarding hormonal therapy were weak and confounded because the therapy was co-administered with surgery and psychotherapy, and data were reported for the sex reassignment process as a whole. The authors also stated that cultural differences should be considered as the findings were mostly derived from European countries and their generalisability to other populations was unknown.

The authors' conclusion reflects the evidence presented but methodological limitations related to the individual studies and the review synthesis suggest that this conclusion should not be considered reliable.

• Implications of the review for practice and research

Practice : The authors stated that prior to treatment clinicians should inform individuals of the uncertain balance between the benefits and harms of hormonal therapy in the sex reassignment context.

Research : The authors stated that further research was required to investigate the benefits and harms associated with hormonal therapy in individuals undergoing sex reassignment. It was also suggested that standardised scales be validated and consistently used to facilitate inference and subgroup comparisons. Cross-cultural studies were suggested as a way of assessing the impact that cultural stigma and victimisation might have on treatment outcomes.

The Endocrine Society, USA.

• Bibliographic details

Hassan Murad M, Elamin MB, Zumaeta Garcia M, Mullan RJ, Murad A, Erwin PJ, Montori VM. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology 2010; 72(2): 214-231. [ PubMed : 19473181 ]

• Original Paper URL

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2009.03625.x/abstract

• Indexing Status

Subject indexing assigned by NLM

Female; Hormones /therapeutic use; Humans; Male; Quality of Life; Sexual and Gender Disorders /drug therapy /psychology

• AccessionNumber

12010006227

• Database entry date
• Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

• Cite this Page Hassan Murad M, Elamin MB, Zumaeta Garcia M, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. 2010. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

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Danielle Laidley among advocates to welcome bid to scrap WA Gender Reassignment Board

Western Australians will no longer have to undergo medical or surgical reassignment in order to change their sex or gender, under the state government's proposed law reforms.

The state's Gender Reassignment Board, which manages applications to legally change a person's gender, would be abolished under the new laws.

Attorney-General John Quigley said the legislation would bring WA in line with the rest of Australia.

"This is not radical legislation … we're only bringing Western Australia out of the dark ages, up to a level of social reform that the rest of the country already respects and enjoys," he said.

Reforms will save lives, advocate says

Danielle Laidley is an AFL premiership winner, and one of the youngest senior coaches in the sport's history.

Laidley was outed as a trans woman by police, had her family turn their back on her, and survived the drugs she turned to as her life spiralled out of control.

"Today I can finally stand here, as a proud Western Australian and transgender woman," she said.

Laidley said the abolition of the Gender Reassignment Board was a step forward for WA.

"It was wrong for someone to sit there and tell me who I was. They haven't walked a mile in my shoes, they don't know how I feel," she said.

Transfolk of WA deputy chairperson Dylan Green said the reform was a significant step to creating a pathway for transgender and gender-diverse people to align legal documentation with their gender identity.

"This will improve the lives, and save the lives, of many trans and gender diverse people in Western Australia," he said.

However, Mr Green noted the state government's proposal did not meet all of the recommendations made by the state's Law Reform Commission in 2018.

"We will be making further recommendations to the government regarding the regulations for this proposed bill, and advocating for further law reform," he said.

"We've seen in other states … certain requirements for clinical evidence have been removed for adults over the age of 18, so they use the self-determination model.

"That is what is widely considered best practice."

More change to come

Under the new laws, adults who have received counselling would be able to apply for a sex-change through the Registry of Births, Deaths and Marriages.

Teenagers between 12 and 18-years-old would need the consent of both parents, and children under 12 would need approval from the WA Family Court.

The legislation also includes clauses prohibiting certain types of offenders from applying to change their gender.

"You don't want someone who, for example, has been convicted of a nasty, aggravated sexual offence, then changing gender so they can access women-only areas," Mr Quigley said.

The proposed bill would also make the sex descriptors "non-binary" and "indeterminate/intersex" available, alongside "male" and "female".

The reforms would not change the existing procedure for registering the sex of a newborn. It also contains a requirement for the legislation to be reviewed after three years.

Mr Quigley has flagged the proposed legislation is only the first tranche of a multitude of changes to remove barriers for, and improve the lives of, the LGBTQIA+ community.

The WA government is chasing further reforms, including the development of a new Equal Opportunity Act and banning conversion therapy practices, which the attorney-general said would have to wait until after the 2025 state election.

"The federal government has announced the Australian Law Reform Commission findings, and the Prime Minister has come out and said on some contentious areas he is hopeful of getting bipartisan support," Mr Quigley said.

"I don't want to come in from left field and upset the applecart."

Reform follows landmark UK review

The proposed law reform comes after a landmark investigation into gender-affirming care in England, known as the Cass Review.

It recommended significantly limiting the prescription of medications, known as puberty blockers, for people aged under 18.

Federal health minister Mark Butler described the review's findings as "significant" but said the clinical treatment of transgender children in Australia was very different than in the UK.

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The Vatican says surrogacy and gender theory are 'grave threats' to human dignity

Jason DeRose

The crowd looks in direction of the window of the apostolic palace overlooking St. Peter's square during Pope Francis' prayer on April 1 in The Vatican. TizianaI Fabi/AFP via Getty Images hide caption

The crowd looks in direction of the window of the apostolic palace overlooking St. Peter's square during Pope Francis' prayer on April 1 in The Vatican.

The Vatican has released a new document calling poverty, war and the plight of migrants "threats to human dignity." But it also calls abortion, surrogacy and gender theory "grave threats" facing humanity today.

The document, titled " Infinite Dignity " says that each person's dignity comes from the love of the creator "who has imprinted the indelible features of his image on every person." This language is familiar to Christians accustomed to hearing that humans are all made in God's image.

The document goes on to say that this dignity is inalienable, beyond any circumstance or situation the person might encounter. Simply put, because a person exists, a human has intrinsic dignity.

"Infinite Dignity" details a long list of what it calls grave threats to that dignity, some of which might be expected given other Catholic teachings. It talks about the drama of poverty and how the unequal distribution of wealth denies humans their God-given dignity. It also describes war, the abuse of migrants, sexual abuse, violence against women, the marginalizing of people with disabilities, assisted suicide and abortion all as affronts to human dignity.

But then the document turns to other issues that have become more highly politicized in recent years: surrogacy, gender theory, and what it calls "sex change."

The pope wants surrogacy banned. Here's why one advocate says that's misguided

The document's framework holds that if a person is made in God's image, gender theory and gender reassignment surgery call into question why God would create a person with the wrong gender.

It says that the understanding of humanity as divided into two sexes — male and female — is biblical and deeply meaningful, especially in terms of procreation. Gender theory argues that a person's gender can be different from the sex that person was assigned at birth.

"Infinite Dignity" says the concept of human dignity can be misused to justify what it calls an "arbitrary proliferation of new rights," describing those, rather, as "individual preference" or "desire." That language is very similar to how conservatives often talk about being transgender as a choice, which is something major medical and psychological groups dispute.

The document makes a clear distinction between the issue of sexual orientation (whether a person is gay, lesbian or bisexual) and the issue of gender identity (whether a person's sex assigned at birth matches what that person understands his or her gender to be).

The document will be seen by some more conservative Catholic as a win after years of feeling embattled during Pope Francis's leadership. Just last year, the Vatican said priests could baptize transgender Catholics and allowed for priests to bless people in same-sex relationships .

Catholic Church works to explain what same-sex blessings are and are not

But many transgender Catholics and their families as well as more progressive Catholics are displeased with "Infinite Dignity."

Executive director of the LGBTQ Catholic group New Ways Ministry, Francis DeBernardo says of the document, "When it gets to the section on people who are transgender or non-binary, it doesn't apply the principles of human dignity to them."

New Ways Ministry's mission is, in part, to help pastors and religious teachers better understand gender identity and sexuality. It also fosters, "holiness and wholeness within the Catholic LGBTQ+ community."

DeBernardo argues "Infinite Dignity" does not live up to its own name. "In a sense, it's not infinite dignity," he says. "It's a very limited dignity that the church is offering."

He fears this document will be used to further persecute transgender people, and he thinks it will cause transgender Catholics and their families to leave the church.

The Vatican says priests can baptize transgender people

DeBernardo also worries the sections on gender theory and what it calls "sex change" will eclipse what he describes as the very good parts of the document on war, poverty and migrants.

The group Catholics for Choice, is also disappointed and calls into question how the document was created. "Yet again," said the group's president Jamie Manson in a written statement, "a group of all-male, celibate clergymen are telling women and gender-expansive people that their lived experiences are not real or valid."

Catholics for Choice advocates within the church on a variety of issues regarding sexual and reproductive health, including abortion rights. The group holds – and argues that Catholic teaching supports – people's individual consciences should be their guide in such decisions.

"It is clear to me that the women and trans people who continue to identify as Catholic — despite documents like this completely disregarding our experiences — only do so because of a deep love for our faith and its traditions," continues Manson in her statement. "It is devastating that our leaders do not offer the same respect and love in return."

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Sweden passes law lowering age to legally change gender from 18 to 16

Proposal sparked intense debate in country but passed with 234 votes in favour and 94 against

Sweden’s parliament has passed a law lowering the minimum age to legally change gender from 18 to 16 and making it easier to get access to surgical interventions.

The law passed with 234 votes in favour and 94 against in Sweden’s 349-seat parliament.

While the Nordic country was the first to introduce legal gender reassignment in 1972, the new proposal, aimed at allowing self-identification and simplifying the procedure, sparked an intense debate in the country.

The center-right coalition of the conservative prime minister, Ulf Kristersson, has been split on the issue, with his own Moderates and the Liberals largely supporting the law while the smaller Christian Democrats were against it.

The Sweden Democrats, the populist party with far-right roots that support the government in parliament but are not part of the government, also opposed it.

“The great majority of Swedes will never notice that the law has changed, but for a number of transgender people the new law makes a large and important difference,” Johan Hultberg, an MP representing the ruling conservative Moderate party, told parliament.

Beyond lowering the age, the new legislation is aimed at making it simpler for a person to change their legal gender.

“The process today is very long, it can take up to seven years to change your legal gender in Sweden,” Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender , Queer and Intersex Rights (RFSL), told AFP.

Two new laws will go into force on 1 July 2025: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

People will be able to change their legal gender at 16, though those under 18 will need the approval of their parents, a doctor and the National Board of Health and Welfare.

A diagnosis of “gender dysphoria” – where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as – will no longer be required.

Surgical procedures to transition would be allowed from the age of 18, but would no longer require the board’s approval. The removal of ovaries or testes will only be allowed from the age of 23, unchanged from today.

Denmark, Norway, Finland and Spain are among countries that already have similar laws.

Last Friday German lawmakers approved similar legislation, making it easier for transgender, intersex and non-binary people to change their name and gender in official records directly at register offices.

In the UK, the Scottish parliament in 2022 passed a bill allowing people aged 16 or older to change their gender designation on identity documents by self-declaration. It was blocked by the British government , a decision that Scotland’s highest civil court upheld in December.

The legislation set Scotland apart from the rest of the UK, where the minimum age is 18 and a medical diagnosis is required.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases. This is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500% since 2008, according to the Board of Health and Welfare.

While tolerance for gender transition has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal.

A poll published this week suggested almost 60% of Swedes oppose the proposal, while only 22% back it.

In a sign of the strong feelings it stirred, members of parliament spent six hours debating the proposal.

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The debate has also weakened conservative Prime Minister Ulf Kristersson's standing, after he admitted to caving into pressure from party members on the issue.

Beyond lowering the age, the proposals also aim to make it simpler for a person to change their legal gender. 

"The process today is very long, it can take up to seven years to change your legal gender in Sweden ," Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL), told AFP.

Under the proposal, two new laws would replace the current legislation: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

If parliament adopts the bill as expected on Wednesday, people will be able to change their legal gender starting at the age of 16, though those under 18 will need the approval of their parents, a doctor, and the National Board of Health and Welfare.

A diagnosis of "gender dysphoria" -- where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as -- will no longer be required.

Surgical procedures to transition would, like now, be allowed from the age of 18, but would no longer require the Board of Health and Welfare's approval.

The removal of ovaries or testes would however only be allowed from the age of 23, unchanged from today. 

Gender dysphoria surging 

A number of European countries have already passed laws making it easier for people to change their legal gender.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008, according to the Board of Health and Welfare.

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

A poll published this week suggested almost 60 percent of Swedes oppose the proposal, while only 22 percent back it. 

Some critics have expressed concerns about biological males in women's locker rooms and prisons, and fear the legal change will encourage confused youths to embark down the path toward surgical transitions.

Others have insisted that more study is needed given the lack of explanation for the sharp rise in gender dysphoria.

Deep divisions 

"There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism," Annika Strandhall, head of the women's wing of the Social Democrats (S-kvinnor), told Swedish news agency TT. 

"We want to pause this (age change) and wait until there is further research that can explain this increase" in gender dysphoria cases.

RFSL's Ponkala disagreed, saying the simplified process was important for transgender people, a "vulnerable" group.

"They face a lot of risks... We see that the political climate has hardened," he said. 

Kristersson, the prime minister, has defended the proposal as "balanced and responsible".

But he has also admitted he wanted to keep the age at 18 but gave in to strong forces in his party.

His own government has been split on the issue, with the Moderates and the Liberals largely in favour and the Christian Democrats and Sweden Democrats against. 

He has had to seek support from the left-wing opposition to get the proposal through parliament.

If adopted, the new law would come into force on July 1, 2025.

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