gender reassignment surgery advantages

Mental health benefits associated with gender-affirming surgery

Gender-affirming surgeries are associated with numerous positive health benefits, including lower rates of psychological distress and suicidal ideation, as well as lower rates of smoking , according to new research led by Harvard T.H. Chan School of Public Health.

The study examined data from the 2015 U.S. Transgender Survey, which included nearly 20,000 participants, 38.8% of whom identified as transgender women, 32.5% of whom identified as transgender men, and 26.6% of whom identified as nonbinary. Of the respondents, 12.8% had undergone gender-affirming surgery at least two years prior and 59.2% wanted to undergo surgery but had not done so yet.

Gender-affirming surgeries were associated with a 42% reduction in psychological distress and a 44% reduction in suicidal ideation when compared with transgender and gender-diverse people who had not had gender-affirming surgery but wanted it, according to the findings. The study also found a 35% reduction in tobacco smoking among people who had gender-affirming surgeries.

“Going into this study, we certainly did believe that the gender-affirming surgeries would be protective against adverse mental health outcomes,” lead author Anthony Almazan, an MPH candidate at Harvard Chan School, said in an April 28, 2021, HealthDay article. “I think we were pleasantly surprised by the strength of the magnitudes of these associations, which really are very impressive and, in our opinion, speaks to the importance of gender-affirming surgery as medically necessary treatment for transgender and gender diverse people who are seeking out this kind of affirmation.”

Read the HealthDay article: Gender-Affirming Surgeries Improve Mental Health in Young, Study Says

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slide toggle Demystifying and Navigating Your Options: Gender Reassignment Surgery

Do you have any questions? Check our F.A.Q. section or contact us directly!

Demystifying and Navigating Your Options: Gender Reassignment Surgery

Medically reviewed by Paul Gonzales on March 25, 2024.

Previously, the term gender reassignment surgery (GRS) referred to genital reconstruction bottom surgeries like vaginoplasty, vulvoplasty, phalloplasty, or metoidioplasty. Individuals who look up this term on a search engine do so looking for information on gender-affirming procedures generally for transgender, non-binary and gender non-conforming people. This detailed guide breaks down everything you need to know about these procedures, their costs, their eligibility requirements, the potential benefits and risks and more. If you are interested in undergoing any gender-affirming or “gender reassignment” surgery, you can schedule a free, virtual consultation with one of our surgeons.

At the Gender Confirmation Center (GCC), we generally avoid using terminology like GRS in a clinical setting out of the recognition that for the vast majority of our patients, surgeries do not “reassign” anyone’s gender. Rather, surgery can help individuals experience greater alignment with their bodies and greater gender euphoria as a result.

Types of Gender “Reassignment” Surgeries: “Female to Male (FTM)”

Female to Male (FTM) is outdated terminology that the GCC does not use in our clinical practice. This abbreviation leaves out the experiences of many trans masculine and non-binary patients who do not identify with being labeled as a “woman becoming a man.” 

In the past, “FTM gender confirmation surgery” was used to describe surgical procedures that reverse the effects of an initial estrogenic puberty or procedures that reconstruct a patient’s genitals. We still receive various inquiries about which “FTM” procedures we offer, so below you can find a list of surgeries that have typically been placed under this label. 

Please note that patients can seek out any of these procedures regardless of their gender identity. The goal of our practice is not to make our patients “into men,” but to help them feel more comfortable, affirmed, and/or aligned with their bodies.

Chest Surgery or Top Surgery

“FTM” top surgery is an antiquated term that refers to gender-affirming chest reconstruction and/or breast reduction. Practices who use this acronym sometimes have limited experience meeting the unique needs of non-binary patients seeking top surgery . Patients who would like to remove their chest tissue to have a flatter chest can choose from a variety of incision options to reach their desired results around chest tightness, contour and/or scar shape. 

Not all patients who pursue top surgery want flat chests. Whether you would like to opt for a breast reduction or a chest reconstruction with some volume left behind, the button buttonhole incision is the most commonly pursued type.

Top surgery patients who would like to maintain an erotic or a high level of sensation in their nipples can ask their surgeon about nerve-preservation techniques . Inversely, many patients who get top surgery choose to have their nipples removed .

Genital Reconstruction or Bottom Surgery

While the following bottom surgery procedures are traditionally put under the “FTM” category, we recognize that not all patients who pursue these procedures identify as men nor are they looking to “masculinize” their genitals.

Two procedures can be used to reconstruct a penis or “neophallus”: metoidioplasty and phalloplasty. Metoidioplasty or “meta” releases the ligaments around the erectile tissue (called a clitoris or penis) to extend it to about 2-4 inches in length. A phalloplasty uses a donor flap (usually from the forearm or thigh) to construct a penis of 4 inches in length or more (depending on availability of tissue). Both procedures can be specialized to allow a patient to maintain erotic sensation in their genitals (nerve preservation) and/or urinate standing up (urethroplasty).

Associated procedures include the removal of the uterus (hysterectomy), the removal of the vaginal canal (vaginectomy), the construction of a scrotum (scrotoplasty), the insertion of penile/testicular implants, and more.

Body Masculinization Surgery (BMS)

Body Masculinization Surgery (BMS) refers to a series of body contouring procedures. Most often, BMS involves liposuction of one or more of the following areas: abdomen, flanks, hips, thighs, buttocks, or arms. BMS can also involve removing unwanted, excess skin from fat loss or liposuction. Occasionally, some patients may opt for silicone pectoral implants alongside or after their top surgery results.

Facial Masculinization Surgery (FMS)

Facial Masculinization Surgery (FMS) refers to a series of procedures that patients can choose from to give their face a more angular, conventionally masculine appearance. In the bottom third of the face, the chin, jaw, or laryngeal prominence (aka Adam’s apple) can be augmented or increased in size. In the middle third of the face, the appearance of the nose and/or cheeks can be altered. In the top third of the face, the hairline’s position can be changed and the forehead can be augmented.

Types of Gender “Reassignment” Surgeries: “Male to Female (MTF)”

Male to Female (MTF) is outdated terminology that we do not use in our clinical practice. This abbreviation leaves out the experiences of many trans feminine and non-binary patients who do not identify with being labeled as a “man becoming a woman.”

In the past, “MTF gender confirmation surgery” was used to describe surgical procedures that reverse the effects of an initial androgenic (testosterone-dominant) puberty and/or reconstruct a patient’s genitals. As a practice, we still get asked by prospective patients about the “MTF” procedures we offer, which is why we have compiled a guide of surgeries that have typically been placed under this category.

Please note that patients can seek out any of these procedures regardless of their gender identity. The goal of our practice is not to make our patients turn “into women,” but to help them feel greater gender congruence with their bodies.

Breast Augmentation or “MTF” Top Surgery

Typically, for trans feminine and non-binary patients who prefer to have more volume on their chest, breast augmentation with saline or silicone implants allows for greater success in their desired outcomes. Fat grafting procedures limit the amount of volume transferred to the chest based on available body fat that can be safely removed.

Genital Reconstruction or Bottom Surgeries

The most common surgeries that are placed under this category are vaginoplasty and vulvoplasty (also called zero-depth vaginoplasty) procedures. The most common vaginoplasty uses a penile-inversion technique to reconstruct a vaginal canal. However, a penile-preserving vaginoplasty is also another option for patients. Lifelong dilation after this procedure is necessary to maintain the depth of the canal so that it can be used for penetrative sex. Labiaplasty revisions are sometimes sought out by patients wishing to adjust the size, shape and symmetry of their labia and/or clitoral hood.

Before a vaginoplasty, patients may opt to remove the testicles ( orchiectomy ). Patients of varying gender identities undergo orchiectomies for many reasons, such as chronic pain or to simplify their hormone therapy.  For patients who plan to have a vaginoplasty in the future, it’s best to consider the timing of an orchiectomy procedure since scrotal tissue can be used to construct the labia.

Facial Feminization Surgery (FFS)

FFS refers to a series of procedures that a patient can choose from to give their face a softer, more conventionally feminine appearance. In the bottom third of the face, the laryngeal prominence (or Adam’s apple), chin, or jaw can be reduced in size. In the middle third of the face, the appearance of the nose and/or cheeks can be altered. In the top third of the face, the hairline’s position can be changed and the forehead can be reduced.

Body Feminization Surgery (BFS)

BFS encompasses a series of body contouring procedures. Most often, BFS involves removal of fat through liposuction of one or more of the following areas: the thighs, the abdomen/waist, or the arms. The fat removed from these areas of the body can be transferred to the buttocks and/or hip areas and is commonly referred to as a Brazilian butt lift (BBL). BFS can also involve removing unwanted excess skin from fat loss or liposuction, a procedure often referred to as a tummy tuck or abdominoplasty.

Evaluating Candidacy for Gender Affirmation Surgery

Strict guidelines evaluate patient readiness for life-altering GRS procedures.

Informed consent

The GCC follows an informed consent model for surgery because it gives patients autonomy over their health. Under this model, adults can consent to procedures if they have received adequate education about their risks, advantages, and potential effects on their health given their unique medical history. Historically, TGD people have had a difficult time accessing quality gender-affirming health care in part because of gatekeeping and discrimination based on requirements set by insurance companies. For example, letters from medical and mental health providers are a part of these requirements. We recognize that therapists and other healthcare providers are invaluable sources of support for patients undergoing a medical gender transition. 

Health factors

We recommend our patients get medical clearance from their primary care provider (PCP) before surgery. If you have medical conditions that may affect your surgery, we can work with your PCP or specialist to ensure a safe recovery. Patients should inform their surgeons of any cardiovascular or respiratory issues, history of anorexia, diabetes, or use of immunosuppressant medications.

Different surgeons may consider a patient’s Body Mass Index (BMI) as part of their eligibility for surgery. You can read more about our requirements and recommendations around BMI here .

We require all our patients to stop smoking or consuming any form of nicotine for at least 3 weeks before and 3 weeks after surgery, as this can lead to significant problems with delayed wound healing. Please do not drink alcohol for at least 1 week before and 1 week after surgery or until prescription pain medications are discontinued.

Insurance requirements

Patients who wish to have their insurance cover their gender affirming surgery need to fulfill certain requirements. You will need to get a letter of support from a mental health professional to confirm that the procedure is medically necessary. If the surgeon is outside of your insurance’s in-network providers, you will need to get a referral letter from your primary care provider (PCP). Additionally, some insurance companies may require that a patient undergo gender-affirming hormone therapy to cover surgery.

Hormone Therapy Considerations

At GCC, we do not require our patients to undergo hormone therapy to access medically necessary, gender-affirming surgeries. That said, undergoing hormones before surgery can help some patients improve the appearance of post-op results.

• Facial surgery: It may take up to 1.5 years on hormone therapy before soft tissue changes can appear on the face so patients should consider waiting to undergo facial surgery until these changes have settled.
• Bottom surgery: Maximal bottom growth may take up to 2 years for patients on a standard dose of testosterone so patients should consider undergoing metoidioplasty until maximal growth is achieved for optimal outcomes.
• Breast augmentation: Maximal breast growth may take up to 1.5 to 2 years for patients on a standard dose of estrogen so patients should consider undergoing breast augmentation until maximal growth is achieved.
• Body contouring: It may take up to 1.5 years on hormone therapy before the fat redistribution process settles so patients should consider waiting until then before undergoing liposuction or fat grafting procedures.

When it comes to age and eligibility for surgery, we are typically asked about 2 populations: adolescents and seniors. The World Professional Association for Transgender Health (WPATH) has outlined in their Standards of Care (SOC), Version 8 , the need for the involvement of caregivers/parents and mental health professionals in the informed consent process for adolescents. If these protocols are followed, the only type of gender-affirming surgery that an adolescent can undergo is top surgery.

As long they are in good health and cleared for surgery, senior patients are eligible for surgery regardless of their age and can achieve good aesthetic outcomes. It’s important to consider what accommodations are necessary to support post-op recovery. You can read more about our eligibility standards here .

Weighing GRS Benefits Against Complications

The decision to undergo “gender reassignment surgery” is a highly personal one. Understanding both the pros and cons provides critical insight.

How GRS Can Transform Lives

The WPATH’s SOC 8 reviews the medical research literature around the long-term effects of gender-affirming surgery on trans and non-binary patients. Gender-affirming procedures report greater satisfaction and lower regret rates compared to similar cosmetic and reconstructive procedures performed in cisgender patients.

• Improved mental health
• Improved body-image, etc.
• Enhanced quality of life

Rates of anxiety, depression, and suicide risk all tend to decrease substantially following surgery for those who need it, which is why these procedures are considered medically necessary for many patients.

Risk Factors and Long-Term Effects

All surgeries carry risks of complications. Generally speaking, patients who optimize their health prior to surgery (e.g., do not smoke tobacco) and manage any pre-existing medical conditions can greatly reduce their risk for complications. Undergoing surgery with a board-certified surgeon who has hospital access privileges can help ensure the integrity of your surgical process. If you have specific questions about surgical complications and how to prevent them, you can consult our content library on this question.

Navigating Emotions

Surgery not only takes a physical, but also an emotional toll on the body. Experiencing pain, inflammation, discomfort and limitations on physical activity occasionally mat result in temporary postoperative depression. Likewise, having to wait weeks or months to have a sense of what your final results from surgery will look like can give some patients temporary feelings of regret during recovery. For this reason, we highly encourage patients to tap into their support networks of friends, (chosen) family and/or mental health professionals during this time. To learn more about the emotional recovery process, click here .

Conclusion: Is Gender Reassignment Surgery the Right Choice?

While gender-affirming surgery has been proven to be positively life-changing for many trans and non-binary individuals. Whether you seek surgery or not, we remain dedicated to your health, empowerment, and right to be your authentic self.

More Articles

Understanding the cost of double incision top surgery: a comprehensive guide, gatekeeping vs. empowerment: accessing gender affirming care, treating gender dysphoria in adolescents, sign up for instructions to get a virtual consultation.

The virtual consultation will be billed to your insurance company. We will accept the insurance reimbursement as payment in full.

Dr. Scott Mosser Suite 1010, 450 Sutter St San Francisco, CA 94108 Phone: (415) 780-1515 Fax: ( 628) 867-6510

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Sex-reassignment surgery yields long-term mental health benefits, study finds

When transgender people undergo sex-reassignment surgery, the beneficial effect on their mental health is still evident — and increasing — years later, a Swedish study suggests.

Overall, people in the study with gender incongruence — that is, their biological gender doesn’t match the gender with which they identify — were six times more likely than people in the general population to visit a doctor for mood and anxiety disorders. They were also three times more likely to be prescribed antidepressants, and six times more likely to be hospitalized after a suicide attempt, researchers found.

But among trans people who had undergone gender-affirming surgery, the longer ago their surgery, the less likely they were to suffer anxiety, depression or suicidal behavior during the study period, researchers reported in The American Journal of Psychiatry.

NBC OUT Baylor professor apologizes after guest speaker promotes conversion therapy

Surgery to modify a person’s sex characteristics “is often the last and the most considered step in the treatment process for gender dysphoria,” according to the World Professional Association for Transgender Health.

Many transgender and gender-nonconforming individuals "find comfort with their gender identity, role, and expression without surgery," but for others, "surgery is essential and medically necessary to alleviate their gender dysphoria," according to the organization.

While the new study confirms that transgender individuals are more likely to use mental health treatments, it also shows that gender-affirming therapy might reduce this risk, coauthor Richard Branstrom of the Karolinska Institutet in Stockholm told Reuters Health by email.

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Branstrom and colleague John Pachankis of the Yale School of Public Health in New Haven, Connecticut found that as of 2015, 2,679 people in Sweden had a diagnosis of gender incongruence, out of the total population of 9.7 million.

That year, 9.3 percent of people with gender incongruence visited a doctor for mood disorders, 7.4 percent saw a doctor for anxiety disorders and 29 percent were on antidepressants. In the general population, those percentages were 1 percent, 0.6 percent and 9.4 percent, respectively.

Just over 70 percent of people with gender incongruence were receiving feminizing or masculinizing hormones to modify outward sexual features such as breasts, body fat distribution and facial hair, and 48 percent had undergone gender-affirming surgery. Nearly all of those who had surgery also received hormone therapy.

The benefit of hormone treatment did not increase with time. But “increased time since last gender-affirming surgery was associated with fewer mental health treatments,” the authors report.

In fact, they note, “The likelihood of being treated for a mood or anxiety disorder was reduced by 8 percent for each year since the last gender-affirming surgery,” for up to 10 years.

NBC OUT LGBTQ advocates applaud judges' rejections of Trump health care rule

Transgender individuals’ use of mental health care still exceeded that of the general Swedish population, which the research team suggests is due at least partly to stigma, economic inequality and victimization.

“We need greater visibility and knowledge about challenges people are confronted with while breaking gender and identity norms,” Branstrom said.

Dr. Joshua Safer, executive director at Mount Sinai Center for Transgender Medicine and Surgery in New York City, told Reuters Health by email, “If anything, the study likely under-reports mental health benefits of medical and surgical care for transgender individuals.”

Safer, who was not involved in the study, said the fact that mental health continued to improve for years after surgery “suggests (surgery provides) extended and ongoing benefit to patients living according to gender identity.”

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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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

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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

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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

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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

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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

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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

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Life After Gender Affirming Surgery: Five Benefits

• Life After Gender Affirming Surgery Five Benefits

Gender affirming surgery includes a wide variety of surgeries for those transitioning from male to female or female to male to help with gender dysphoria. There are many different types of surgeries that can be considered gender affirming surgery but they all have the goal of helping the patient affirm the gender they identify as and are transitioning to. These different surgeries help the patient look and feel more masculine or feminine and are greatly beneficial to the patient and their overall journey. 

Different surgery options include, but are not limited to:

• Body contouring
• Rhinoplasty
• Breast augmentation
• Buttock/hip enhancement
• Rib reduction
• Vaginoplasty
• Phalloplasty
• Masculinizing chest surgery
• Facial feminization surgery
• Voice surgery
• Tracheal shave
• Facial masculinization surgery

Knowing the benefits of surgery beforehand can greatly help patients make the right decision about whether to move forward with their desired surgery with peace of mind.

Below we’ll discuss five benefits of gender affirming surgeries and what patients can look forward to with life after. 

Long-Term Mental Health Benefits

Research shows that one of the main benefits of gender affirming surgery is the wide array of long-term mental health benefits patients experience. Some studies report that patients who underwent gender affirming surgeries experienced lower rates of psychological distress and suicidal ideation. Another study found that a person’s odds for needing mental health treatment declined by 8% each year after gender affirming surgery.

More and more studies showing the large number of mental health benefits patients are experiencing post-surgery confirm the importance of gender procedures as medically necessary treatments for transgender people.

Higher Quality of Life

Many transgender patients before undergoing gender affirming procedures are looking to have a higher quality of life living as their identifying gender and believe that gender affirming procedures will help provide that. As you might imagine, a higher quality of life is a benefit many patients experience after undergoing surgery. While hormone therapy can make a big difference in one’s transition journey, gender affirming procedures are essential for helping transgender people truly look and feel like themselves. 

One study measuring transgender patients’ overall quality of life post-surgery found that three-quarters of patients who underwent a gender affirming surgery have a better quality of life now.

Improved Sexuality

One main concern for transgender people is how their sexuality and experience will change throughout their transition journey. This is especially true for patients who desire to undergo any type of bottom surgery. Common concerns brought up by patients are their ability to experience sexual satisfaction after surgery. Fortunately, many studies have found that transgender patients have reported that they experienced higher levels of sexual satisfaction after gender surgery.

One study shows that over 75% of patients were able to achieve orgasm after surgery. Transgender patients have reported being able to reach orgasm more easily and experience more frequent sexual satisfaction than they had before surgery. 

Better Self Image

A number of pre-surgery transgender patients struggle with low self-image, self-esteem, and with positive body image because they don’t look and feel masculine or feminine enough. One of the benefits many patients hope to experience from surgery is feeling more confident in themselves and their gender. One study of transgender men showed that participants had lower self-esteem than cis-gender men and that a mastectomy improved their body image, self-esteem, and self-worth.

Improved Social Affirmation

While transgender people can make a lot of nonsurgical changes to more closely identify with their gender for themselves and to signal others, it can feel challenging for many to affirm their gender socially and feel accepted pre-gender affirming surgery. For some people, changing their pronouns, name, and clothing doesn’t feel like enough to fit in.

Gender affirming surgery allows a trans patient’s physical attributes to align more closely with their self-identified gender and appear as their self-identified gender to others as well. Not only do gender affirming surgeries help trans patients feel more socially accepted, but they also help patients feel more confident overall in public and social settings. 

The Bottom Line

As gender affirming surgeries are being studied more and more, the known benefits of life after surgery continue to grow. It’s clear that gender affirming surgeries are a necessity for overall quality of life for transgender people. While many patients have concerns before going through these big, life-changing procedures, knowing the benefits that lie ahead can be comforting. 

In addition to knowing the benefits, it’s also essential to undergo a consultation with a surgeon before making any final decisions. This ensures that you’re a good candidate for surgery and that you choose the best procedures to reach your desired outcome.

Ready to get started on your gender affirming surgery journey? Leif Rogers, MD, is an Ivy League-educated, board-certified plastic surgeon and a standing member of the American Society of Plastic Surgeons. To schedule a consultation, get in touch with our team today.

Your Path to Perfection begin your radiant transformation

This is the beneficial effect of sex-reassignment surgery early on in a transition

Surgery "is often the last and the most considered step in the treatment process for gender dysphoria". Image:  REUTERS/Gleb Garanich

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When transgender people undergo sex-reassignment surgery, the beneficial effect on their mental health is still evident - and increasing - years later, a Swedish study suggests.

Overall, people in the study with gender incongruence - that is, their biological gender doesn’t match the gender with which they identify - were six times more likely than people in the general population to visit a doctor for mood and anxiety disorders. They were also three times more likely to be prescribed antidepressants, and six times more likely to be hospitalized after a suicide attempt, researchers found.

But among trans people who had undergone gender-affirming surgery, the longer ago their surgery, the less likely they were to suffer anxiety, depression or suicidal behavior during the study period, researchers reported in The American Journal of Psychiatry.

Surgery to modify a person’s sex characteristics “is often the last and the most considered step in the treatment process for gender dysphoria,” according to the World Professional Association for Transgender Health.

Many transsexual, transgender, and gender-nonconforming individuals "find comfort with their gender identity, role, and expression without surgery," but for others, "surgery is essential and medically necessary to alleviate their gender dysphoria," according to the organization. (bit.ly/2WEn9Lg)

Have you read?

This is the state of lgbti rights around the world in 2018.

While the new study confirms that transgender individuals are more likely to use mental health treatments, it also shows that gender-affirming therapy might reduce this risk, coauthor Richard Branstrom of the Karolinska Institutet in Stockholm told Reuters Health by email.

Branstrom and colleague John Pachankis of the Yale School of Public Health in New Haven, Connecticut found that as of 2015, 2,679 people in Sweden had a diagnosis of gender incongruence, out of the total population of 9.7 million.

That year, 9.3% of people with gender incongruence visited a doctor for mood disorders, 7.4% saw a doctor for anxiety disorders, and 29% were on antidepressants. In the general population, those percentages were 1%, 0.6% and 9.4%, respectively.

Just over 70% of people with gender incongruence were receiving feminizing or masculinizing hormones to modify outward sexual features such as breasts, body fat distribution, and facial hair, and 48% had undergone gender-affirming surgery. Nearly all of those who had surgery also received hormone therapy.

The benefit of hormone treatment did not increase with time. But “increased time since last gender-affirming surgery was associated with fewer mental health treatments,” the authors report.

In fact, they note, “The likelihood of being treated for a mood or anxiety disorder was reduced by 8% for each year since the last gender-affirming surgery,” for up to 10 years.

Transgender individuals’ use of mental health care still exceeded that of the general Swedish population, which the research team suggests is due at least partly to stigma, economic inequality and victimization.

“We need greater visibility and knowledge about challenges people are confronted with while breaking gender and identity norms,” Branstrom said.

Dr. Joshua Safer, executive director at Mount Sinai Center for Transgender Medicine and Surgery in New York City, told Reuters Health by email, “If anything, the study likely under-reports mental health benefits of medical and surgical care for transgender individuals.”

Safer, who was not involved in the study, said the fact that mental health continued to improve for years after surgery “suggests (surgery provides) extended and ongoing benefit to patients living according to gender identity.”

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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

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

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This article has been updated

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

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

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

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

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

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

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

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Principles and outcomes of gender-affirming vaginoplasty

Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review

The effect of early puberty suppression on treatment options and outcomes in transgender patients

Change history, 26 april 2011.

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

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• Introduction
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Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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

Affiliations.

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

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

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

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

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

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

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

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Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery

John j straub.

1 Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA

Krishna K Paul

Lauren g bothwell, sterling j deshazo, georgiy golovko.

2 Department of Pharmacology, University of Texas Medical Branch at Galveston, Galveston, USA

Michael S Miller

3 Department of Psychiatry and Behavioral Services, University of Texas Medical Branch at Galveston, Galveston, USA

Dietrich V Jehle

Introduction.

With the growing acceptance of transgender individuals, the number of gender affirmation surgeries has increased. Transgender individuals face elevated depression rates, leading to an increase in suicide ideation and attempts. This study evaluates the risk of suicide or self-harm associated with gender affirmation procedures.

This retrospective study utilized de-identified patient data from the TriNetX (TriNetX, LLC, Cambridge, MA) database, involving 56 United States healthcare organizations and over 90 million patients. The study involved four cohorts: cohort A, adults aged 18-60 who had gender-affirming surgery and an emergency visit (N = 1,501); cohort B, control group of adults with emergency visits but no gender-affirming surgery (N = 15,608,363); and cohort C, control group of adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery (N = 142,093). Propensity matching was applied to cohorts A and C. Data from February 4, 2003, to February 4, 2023, were analyzed to examine suicide attempts, death, self-harm, and post-traumatic stress disorder (PTSD) within five years of the index event. A secondary analysis involving a control group with pharyngitis, referred to as cohort D, was conducted to validate the results from cohort C.

Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001). Compared to the tubal ligation/vasectomy controls, the risk was 5.03-fold higher before propensity matching and remained significant at 4.71-fold after matching (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001) for the gender affirmation patients with similar results with the pharyngitis controls.

Gender-affirming surgery is significantly associated with elevated suicide attempt risks, underlining the necessity for comprehensive post-procedure psychiatric support.

The prevalence of transgender individuals in the United States is approximately 0.3% to 0.6% of the adult population based on self-reporting studies [ 1 ]. Investigations that only include individuals with transgender diagnostic codes, hormone therapy, or gender-affirming surgery report a much lower rate of approximately 0.008% of the population [ 2 ]. People who identify as transgender are shown to have a higher risk of suicide in the United States and across many other countries [ 3 - 6 ].

In 2021, the Centers for Disease Control reported that 48,183 people died by suicide in the United States. Depression, substance abuse, other mental illness, legal/financial problems, harmful relationships, community risk factors, and easy access to lethal means are contributing factors to successful suicide. Transgender individuals have a higher prevalence of depression across several age groups, often due to life experiences that include discrimination, harassment, violence, misgendering, and enacted stigma that may generate poor mental health outcomes and harmful behaviors [ 4 , 7 , 8 ]. It is widely accepted that depression puts an individual at higher risk for suicidal ideation and suicide attempts [ 9 ]. Individuals at higher risk for suicide and post-traumatic stress disorder (PTSD) should have comprehensive psychiatric interventions and care throughout their lifetime. A better understanding of the relationship between suicide and gender affirmation remains particularly important.

There is ongoing controversy surrounding the benefits of gender-affirmation surgery on mental health [ 10 - 20 ]. This controversy reflects diverse perspectives within the medical and research communities, emphasizing the need for a more comprehensive understanding of the psychological outcomes of gender-affirming procedures. Despite the increasing acceptance of transgender individuals, questions persist about the psychological outcomes of gender-affirming procedures. Responses to the discussion surrounding the benefits of gender-affirmation surgery have been diverse, as evidenced by studies conducted by Branstrom and colleagues [ 11 ], Almazan et al. [ 13 ], and others [ 10 , 14 - 20 ].

The purpose of this study is to assess the risk of adverse outcomes, specifically suicide, death, self-harm, and PTSD in the five years following gender-affirmation surgery. Suicide risk over time among patients who received gender-affirmation surgery is compared to individuals in several control groups. The TriNetX (TriNetX, LLC, Cambridge, MA) database will be utilized to better understand the relationship between sex change and these outcomes.

This article was previously presented virtually as a meeting abstract at the 2023 Texas College of Emergency Physicians (TCEP) Research Forum on April 07, 2023.

Materials and methods

TriNetX is a global health research network providing access to de-identified retrospective electronic medical records. The database consists of over 90 million patients from 56 healthcare organizations (HCOs) within the United States. This study utilized TriNetX to identify patients who had a “personal history of sex reassignment” and evaluate their relative risk for suicide attempt, death, suicide/self-harm, and PTSD. The term “sex reassignment” was based on the International Classification of Diseases, 10th Revision (ICD-10) code in the database but will be referred to as the current term “gender-affirmation surgery” for the remaining article. All outcomes were evaluated during the five years after gender-affirmation surgery.

Patients who have undergone gender-affirmation surgery of all sexes, races, and ethnicities were identified by using the ICD-10 code, ICD10CM:Z87.890. Sex, race, and ethnicity were derived from the electronic medical record. Patients who have undergone gender-affirmation surgery are identified by their affirmed gender. A total of four cohorts were identified for this study. Cohort A consisted of patients ages 18 to 60 who had both gender-affirmation surgery and an emergency visit. Cohort B was the study control group that consisted of patients ages 18 to 60 who had no history of gender-affirmation surgery but had an emergency visit. In this database, propensity matching is not possible for very large cohorts, more than 8.3 million patients with 12 covariates.

Additional control groups were chosen to perform propensity matching, which controls for confounders. Cohort C was the study's second control group and consisted of adult patients (18-60 years) who had no history of gender-affirmation surgery, had an emergency visit, and had a tubal ligation or vasectomy. Patients who had undergone tubal ligation were identified through the ICD-10 code, ICD10CM:Z98.51, while the vasectomy procedure was identified by Current Procedural Terminology (CPT), CPT:55250. A secondary sub-group analysis, cohort D, was performed utilizing acute pharyngitis (ICD10CM:J02) as a control group for patients aged 18-60 that was run on June 2, 2023. This was performed to ensure that the vasectomy or bilateral tubal ligation (BTL) group acted as an appropriate control. The relative risk for suicide attempt, death, suicide/self-harm, and PTSD was evaluated during the five years following gender-affirmation surgery in comparison to those without gender-affirmation surgery with the diagnosis of pharyngitis. Cohort A was used again and compared with cohort D, which included patients presenting to the emergency room after diagnosis of acute pharyngitis.

The outcome analysis between the three cohorts was performed for four events: suicide attempt (ICD10CM:T14.91), death (vital status: deceased), suicide/self-harm (ICD10CM:T14.91 or ICD10CM:X71-X83), and PTSD (ICD10CM:F43.1). An analysis was performed utilizing the measures contained in the TriNetX platform, which compared the individual outcomes between cohorts A and B and also cohorts A and C within the designated time frame. Patients who had the outcome before the time window were excluded from the analysis. The final TriNetX data reported RR, 95% CI, ORs, and a risk comparison expressed as a p-value. To control potentially confounding risk factors for the measured outcomes, the propensity matching tool in TriNetX was utilized. Factors involved in the data propensity matching are based on age at index, race, ethnicity, and sex. Propensity matching was only performed between the comparison of cohorts A and C, but not cohort B, due to the large sample size limitation.

Propensity score matching (PSM) is often used in observational studies to reduce confounding biases. It has been investigated and well-documented regarding its properties for statistical inference. PSM is a quasi-experimental method in which the researcher uses statistical techniques to construct an artificial control group by matching the affected group with a non-affected group of similar characteristics. Using these matches, the researcher can estimate the difference between both groups without the confounding variables’ influence [ 21 ]. To justify our use of propensity matching for age, race, sex, and ethnicity, we considered established risk factors for suicide such as older age, male gender identity, and racial or ethnic minority status [ 3 , 4 ].

The cohort was analyzed descriptively using univariate and bivariate frequencies with chi-square and t-testing to assess differences. All eligible persons in the cohort were analyzed using both binary event estimation with RRs, 95% CIs, and probability values. Using the TriNetX database, a 1:1 propensity match using linear and logistic regression for age, sex, race, and ethnicity was employed for maximum generalization of the United States population. Greedy nearest-neighbor matching was used with a tolerance of 0.1 and a difference between propensity scores less than or equal to 0.1. Comparisons were made between cohorts before and after propensity matching. Statistical significance was set at a two-sided alpha <0.05. TriNetX provides data that have been de-identified, and as a result, an Institutional Review Board (IRB) review is not required for this study [ 22 ]. Three comparison reports were generated on February 4, 2023. Data gathered from HCOs was from February 4, 2003, to February 4, 2023.

We identified 15,609,864 adult patients from TriNetX who were adults and had a visit to an emergency department within the United States Collaborative Network. Cohort A consisted of 1,501 adult patients who had a visit to the emergency department and a history of gender-affirmation surgery. Cohort B consisted of 15,608,363 patients who had an emergency visit but no history of gender-affirmation surgery. Cohort C consisted of 142,093 adult patients who had a visit to the emergency department and no history of gender-affirmation surgery but had a vasectomy or BTL.

Without propensity matching between cohorts A and B, patients with a history of gender-affirmation surgery exhibited a significantly higher risk for each possible outcome compared to patients without a history of gender-affirmation surgery (Table ​ (Table1). 1 ). Patients who had a history of gender-affirmation surgery had a 12.12 times greater risk of suicide attempts (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001) vs. patients who had no history of gender-affirmation surgery. In patients with a history of gender-affirmation surgery, there was a 3.35 times greater risk of being deceased (4.9% vs. 1.5%, RR 95% CI 2.673-4.194, p < 0.0001). Patients with a history of gender-affirmation surgery had a 9.88 times higher risk of self-harm or suicide (4.5% vs. 0.5%, RR 95% CI 7.746-12.603, p < 0.0001). Lastly, patients who had a history of gender-affirmation surgery had a 7.76 times higher risk of PTSD (9.2% vs. 1.2%, RR 95% CI 6.514-9.244, p < 0.0001).

PTSD, post-traumatic stress disorder

Before the propensity matching of cohorts A and C, there was a significantly higher risk for each outcome when considering patients with a history of gender-affirmation surgery compared to those without a history of gender-affirmation surgery but with a prior vasectomy or BTL (Table ​ (Table2). 2 ). Patients with a history of gender-affirmation surgery had a 5.03 times higher risk of suicide attempts (3.5% vs. 0.7%, RR 95% CI 3.795-6.676, p < 0.0001), a 2.37 times higher risk of being deceased (4.9% vs. 2.1%, RR 95% CI 1.889-2.982, p < 0.0001), a 5.44 times higher risk of suicide or self-harm (4.5% vs. 0.8%, RR 95% CI 4.233-6.981, p < 0.0001), and a 3.74 times higher risk of PTSD (9.2% vs. 2.5%, RR 95% CI 3.125-4.463, p < 0.0001) compared to patients without a history of gender-affirmation surgery but with a prior vasectomy or BTL.

After propensity matching of cohorts A and C, each cohort had 1,489 patients of similar age at index, race, and ethnicity (Tables ​ (Tables3 3 - ​ -4). 4 ). Patients who had a history of gender-affirmation surgery compared to patients without a gender-affirmation surgery history but had a vasectomy or BTL showed significantly higher risks for each outcome (Table ​ (Table3). 3 ). The adjusted suicide attempt risk for patients with gender-affirmation surgery compared to no history of gender-affirmation surgery but with a prior BTL or vasectomy was adjusted to a 4.71 times greater risk (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001). The risk of being deceased was 4.26 times greater in patients with a history of gender-affirmation surgery vs. patients with no history of gender-affirmation surgery but vasectomy or BTL (4.9% vs. 1.1%, RR 95% CI 2.520-7.191, p < 0.0001). Patients with a history of gender-affirmation surgery showed a 5.10 times higher risk of suicide or self-harm compared to patients with no history of gender-affirmation surgery but vasectomy or BTL (4.5% vs. 0.9%, RR 95% CI 2.816-9.227, p < 0.0001). Lastly, patients with a history of gender-affirmation surgery showed a 3.23 times higher risk for PTSD compared to patients with no history of gender-affirmation surgery but vasectomy or BTL (9.2% vs. 2.8%, RR 95% CI 2.278-4.580, p < 0.0001).

Cohort A: Adult patients who had a visit to the emergency department and a history of sexual reassignment.

Cohort C: Adult patients who had a visit to the emergency department and no history of sexual reassignment but had a vasectomy or bilateral tubal ligation.

The secondary sub-group analysis utilizing pharyngitis (N = 1,390,880) as a control revealed that patients presenting to the emergency department with a history of gender-affirmation surgery had a 7.95 times greater risk of suicide attempt than patients with pharyngitis (1.5% vs. 0.2%, RR CI 5.379-11.755, p < 0.0001), a 3.65 times greater risk of death (4.6% vs. 1.3%, RR CI 2.921-4.563, p < 0.0001), a 7.33 times greater risk of suicide or self-harm (2.7% vs. 0.4%, RR CI 5.448-9.850, p < 0.0001), and a 4.61 times greater risk of PTSD (9.2% vs. 2.0%, RR CI 3.901-5.438, p < 0.0001) compared to patients who were sent to the emergency department following acute pharyngitis. After propensity matching, mortality was 3.59 times greater in patients with a history of gender-affirmation surgery (4.6% vs. 1.3%, RR CI 2.224-5.806, p < 0.0001), and PTSD was 5.49 times greater (9.2% vs. 1.7%, RR CI 3.648-8.267, p < 0.0001) compared to patients with acute pharyngitis. There were too few suicides or self-harm outcomes to report results from the propensity-matched pharyngitis group. These results were similar to the results with cohort C.

The purpose of this study was to explore the relationship between gender-affirmation surgery and the risk of suicide outcomes compared to two control groups with data from 2003 to 2023. The significance of this investigation lies not only in its scale but also in its methodology, as it relies on real-world data rather than meta-analyses and self-reported surveys.

The first controlled group was a large number of patients who had emergency department visits but had not had gender-affirmation surgery. Propensity matching is not possible in the TriNetX database for large groups with millions of patients like the first control group. The second control group consisted of individuals who had not had gender-affirmation surgery but had either a vasectomy or BTL. This control group was selected to allow for propensity matching. Propensity matching was done for this comparison to control for the confounding influence of age, sex, and race/ethnicity. This is particularly important since the rate of successful suicide is much higher in men. At the start of this study, the hypothesis that was proposed predicted individuals who had undergone gender-affirmation surgery would have a greater risk of suicide, death, and self-harm compared to the two controls. This was confirmed by comparing the two control groups. In the second analysis, it was determined that patients who had undergone gender affirmation had a statistically significant increase in suicide attempts, death, self-harm, and PTSD after completion of gender affirmation in comparison with those who had undergone BTL or vasectomy and had not undergone gender-affirmation before propensity matching. After propensity matching our cohorts for age at index, race, and ethnicity, we also found a statistically significant increased risk of suicide attempts, death, self-harm/suicide, and PTSD. These outcomes confirmed the hypothesis. The secondary sub-group analysis utilizing pharyngitis as a control showed results that were comparable to the BTL/vasectomy control group, validating cohort C as an appropriate control group for propensity matching.

These data are supported by previous studies from multiple geographic regions of the globe, including Lebanon [ 3 ], Turkey [ 3 ], Pakistan [ 4 ], China [ 5 ], and Canada [ 6 ], as well as data from within the United States [ 3 - 4 , 6 ]. The large size of our study is an asset to our findings, which will help further our understanding of the relationship between sex change and suicide. To our knowledge, a study of this size has not been described in the literature. Using two control groups, a) those who had not experienced gender-affirmation surgery and had presented to the emergency department and b) a group that had not experienced gender-affirmation surgery, had visited the emergency department, and had a vasectomy or BTL, also helped effectively control for confounding variables utilizing propensity matching. Over the last 20 years, this study demonstrated a 12.12 times greater risk of suicide utilizing the first control group and a 4.71 to 5.03 times increased risk with the other control groups.

Transgender individuals, encompassing both those seeking gender-affirming surgery and those who have undergone it, demonstrate a significantly elevated risk of developing PTSD compared to the general population [ 10 , 23 ]. Among those who seek access to gender-affirming surgery, the commonality of discrimination, interpersonal assault, and a lack of social support have been identified as influential factors in the development of PTSD within this group [ 23 ]. Financial stress and insufficient insurance coverage prove to be significant obstacles for those trying to access gender-affirming surgery. Additionally, the limited availability of medical professionals with expertise in gender-affirming procedures, particularly in areas of lower socioeconomic status, further exacerbates the challenges faced by individuals seeking such care [ 10 ]. However, it is important to consider PTSD development in those who have undergone gender-affirming procedures. The emergence of PTSD following surgery often stems from the pre-operative challenges (such as harassment, limited social support, etc.) in conjunction with suboptimal surgical outcomes and insufficient psychiatric assistance.

This study has revealed a significantly elevated prevalence of PTSD in post-operative transgender individuals, with a 7.76-fold increase in comparison to cohort B and a 3.74-fold increased risk compared to cohort C after propensity matching. These findings were consistent with other studies investigated previously. A study conducted by Livingston et al. in 2022 used probabilistic and rule-based modeling on Veterans Health Administration (VHA) records from 1999 to 2021 to assess the differences in PTSD prevalence among 9,995 transgender and 29,985 cisgender veterans (1:3 ratio). They concluded that transgender veterans experienced PTSD at 1.5-1.8 times the rate of veterans identifying as cisgender, especially higher in recent users of VHA services [ 24 ]. There have proven to be many obstacles when comparing our findings to other studies assessing general population PTSD risk in those who have undergone gender-affirmation surgery. A 2018 systematic review conducted by Valentine et al. showed that many studies used assessment tools not particularly appropriate for evaluating mental health in transgender or gender non-conforming individuals [ 25 ]. The poor psychometric framework has led to many studies not acknowledging confounding and contextual variables, such as exposure to discrimination or minority identity when assessing PTSD in this demographic [ 10 , 25 ]. To avoid the repeated shortcomings of prior research, future studies should employ rigorous and reliable assessment tools such as cross-sectional studies or the collection of prospective data [ 25 ]. Improving transgender representation in emerging PTSD treatment trials is another step in improving the understanding and management of PTSD in transgender individuals [ 10 ].

In light of the examination of the relationship between gender-affirmation surgery and mental health outcomes discussed in this study, it is imperative to acknowledge the broader landscape of research on this topic. Our investigation contributes broad insight, examining real-world data over two decades and encompassing a diverse cohort. However, to further expand upon the contextual significance, it is essential to compare findings from other studies that explore multifaceted aspects of mental health post-gender-affirmation surgery. A study published in the American Journal of Psychiatry by Branstrom et al. in October 2019 drew strong conclusions regarding the positive impact of gender-affirmation surgery on mental health [ 11 ]. However, the study faced criticism of its methodology, leading to a correction/retraction by the journal's editors that stated, "the results demonstrated no advantage of surgery about subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts” [ 12 ]. In a subsequent study conducted in 2021, Almazan et al. compared the mental health outcomes of a group of patients who were not approved for gender-affirmation surgery with a group that had undergone the surgery [ 13 ].

Their findings suggested better mental health outcomes for those who underwent surgery, but notable limitations warrant careful interpretation. First, the study conducted a comparison between two groups: one that had not been approved for surgery, a process requiring two mental health screenings as per the World Professional Association for Transgender Health's standard of care recommendations, and another group that had already undergone surgery. Therefore, it is plausible that the surgery group could inherently have been healthier, irrespective of the surgery. Second, when the analysis was broadened to include lifetime outcomes, the positive association with the surgery became insignificant [ 14 ].

Although our study has revealed a statistically significant increase in suicide risk among those who have undergone gender-affirming surgery, it remains vital to recognize and support the positive impacts that these surgical interventions can have on the lives of transgender individuals. The results of a study by Park et al., published in October 2022 in the Annals of Plastic Surgery, provide a different perspective on the enduring effectiveness and consequences of gender-affirmation surgery [ 20 ]. While our research specifically examined the risk of suicide, death, self-harm, and PTSD in the five years following surgery, Park et al. surveyed the outcomes of 15 gender-affirming surgeries over a more extended period. Their results reveal an improvement in patient well-being, with high satisfaction levels, reduced dysphoria, and persistent mental health benefits even decades after surgery. Notably, the study highlights the durability of these positive outcomes and significantly reduced suicidal ideation following gender-affirmation surgery.

The number of non-gender-conforming individuals continues to increase globally. It is likely, therefore, that a growing number of medical professionals will care for an individual who has undergone gender-affirmation at some point in their career. Apart from additional assistance in surgical recovery, the most common aftercare needs for patients following gender-affirmation surgery is consultation with a mental health professional [ 26 ]. To properly address the mental health needs of transgender individuals, Lapinski et al. emphasize the significance of cultural competency, a patient-focused approach, and collaborative efforts involving psychiatric professionals [ 27 - 30 ]. Transgender individuals tend to see mental health care providers and face discrimination in clinical settings at a far higher rate than the cis-gendered population [ 27 , 28 , 30 ]. Competent medical care following gender-affirming surgery is vital in effectively managing PTSD and its respective mental health challenges for this population [ 27 ].

It is important to note that this study has several limitations. The retrospective cohort design can only demonstrate associations but not causality. However, the larger size of this study, in conjunction with propensity matching, gives this investigation a greater power to identify differences between groups. Additionally, with the extensive timeline of data collection, the findings are relevant and contemporary to modern situations. A limitation of the study design could include the fact that only adult data was analyzed, so the research cannot be generalized to those under the age of 18. The data were also only extracted from a population of residents from the United States. Patients who have undergone gender-affirmation surgery and our control groups may have refrained from disclosing their suicidal ideations or other psychiatric symptoms to their medical providers, potentially influenced by societal pressures or other factors such as perceived attitudes toward those with psychiatric complaints. It may be worth examining if groups considering gender-affirmation surgery who have not yet received the surgery share the same increased risk levels for suicidal actions and ideations. However, given the standard practice of undergoing psychiatric testing before being approved for gender-affirmation surgery, individuals contemplating the procedure may potentially pose a greater suicide risk compared to those who have been approved for surgery.

Conclusions

The results of this study show that gender-affirmation surgery is associated with a significantly higher risk of suicide, death, suicide/self-harm, and PTSD compared to control groups in this real-world database. With suicide being one of the most common causes of death for adolescent and middle-aged individuals, it is clear that we must work to prevent these unfortunate outcomes. This further reinforces the need for comprehensive psychiatric care in the years that follow gender-affirmation surgery.

Greedy nearest-neighbor matching

The most common implementation of propensity matching is pair-matching, in which pairs of treated and control participants are formed. There are several common implementations of pair-matching. The most commonly used is greedy nearest-neighbor matching (NNM), which we used, in which a treated participant is selected at random and then matched to the control participant whose propensity score is closest to that of the treated participant. The process is described as greedy because, at each stage, the control is selected who is closest to the currently considered treated participant, even if that untreated participant would serve better as a control for a subsequently treated participant. This process is then repeated until a matched control participant has been selected for each treated participant. This process generally uses matching without replacement so that once a control participant is matched to a treated participant, that control participant is no longer available to match to a subsequently treated participant. A refinement to NNM is NNM with a caliper restriction. Using this approach, a control participant is an acceptable match for a treated participant only if the difference in their propensity scores is less than a maximum amount (the caliper width or distance). For technical reasons, one typically matches the logit of the propensity score and uses a caliper width that is defined as a proportion of the (0.1-0.2) SD of the logit of the propensity score. A crucial step in any study that uses PSM is to assess the degree to which matching the propensity score resulted in the formation of a matched sample in which the distribution of baseline characteristics is similar between treated and control participants. This assessment is critical as it allows both the researcher and readers to assess whether matching the estimated propensity score has removed systematic baseline differences between treatments. The use of the standardized difference, which is the difference in means in units of SD, is often used for assessing the similarity of matched treated and control participants. Some authors have suggested that a threshold of 0.10 (or 10%) be used to denote acceptable balance after matching. Once an acceptable balance has been achieved, analysts can unblind themselves to the outcome and compare outcomes between treated and control participants in the matched sample. The analyses conducted in the propensity score-matched sample can be similar to those that would be done in an RCT with a similar outcome.

Funding Statement

This study was conducted with the support of the Institute for Translational Sciences at the University of Texas Medical Branch, supported in part by a Clinical and Translational Science Award (UL1 TR001439) from the National Center for Advancing Translational Sciences, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have declared that no competing interests exist.

Author Contributions

Acquisition, analysis, or interpretation of data:   Krishna K. Paul, John J. Straub, Lauren G. Bothwell, Sterling J. Deshazo, Georgiy Golovko, Michael S. Miller, Dietrich V. Jehle

Drafting of the manuscript:   Krishna K. Paul, John J. Straub, Lauren G. Bothwell, Sterling J. Deshazo, Dietrich V. Jehle

Critical review of the manuscript for important intellectual content:   Krishna K. Paul, John J. Straub, Lauren G. Bothwell, Sterling J. Deshazo, Georgiy Golovko, Michael S. Miller, Dietrich V. Jehle

Supervision:   Krishna K. Paul, Dietrich V. Jehle

Concept and design:   Georgiy Golovko, Dietrich V. Jehle

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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People Who Undergo Gender-Reassignment Surgery Have a 12x Increased Risk of Suicide

People who undergo gender-reassignment surgery have a 12x increased risk of attempting to commit suicide, according to a new study, as well as suffering other mental-health problems like PTSD and self-harm. The study, published in the journal Cureus, clearly shows that undergoing gender-reassignment, where the patient’s genitals are surgically rearranged and they also embark on a regimen of hormonal therapy, carries significant, potentially deadly, risks. The researchers note, “There is ongoing controversy surrounding the benefits of gender-affirmation surgery on mental health.” Their aim was to explore the risk of “adverse...

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More News about General News from the Left , Center and Right

From the left, from the center, from the right.

Bill proposed to allow gender change without surgery

A bill has been proposed to allow anyone to change their legal gender without having to undergo sex reassignment surgery.

Rep. Jang Hye-yeong and nine other lawmakers proposed the bill on Monday to ensure "the right to self-determination," saying the judicial guideline that de facto demands such surgery for legal gender change is too intrusive.

Without any law in place regarding the issue, many of those seeking to change their gender status find the process convoluted and even "insulting" as they face questions deemed too personal or unnecessary, they noted.

The bill also aims to strengthen their right to privacy. If passed, those found to have leaked information about their gender change could face up to three years in prison or a maximum fine of 30 million won ($22,000).

Yet the chances of the bill passing the National Assembly are close to zero, as major parties remain reluctant to vote for the bill.

Rep. Kim Hong-gul of the Democratic Party of Korea was the only major party lawmaker to sign the bill.

‘Butchers were murderously wrong’: New study finds risk of suicide jumps 12-fold AFTER gender surgery

A new study has found that people who’ve undergone transgender surgery boast a much higher risk of committing suicide.

Published last month in Cureus, a medical science journal, the study specifically found that “[g]ender-affirming surgery is significantly associated with elevated suicide attempt risks.”

The researchers reached this conclusion by analyzing the healthcare data of 90 million adults aged 18 to 60. They specifically looked at emergency room treatment data for those who’d undergone transgender surgery.

The patients were divided into four groups — one containing people who’d undergone transgender surgery and an E.R. visit, and one containing people who’d undergone no transgender surgery but who had partaken in an E.R. visit.

The third group included “adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery,” and the fourth group included patients with pharyngitis.

https://t.co/XttOf6tqDP As usual, #Democrats have taken a word and twisted its meaning. I don’t see from the results how mutilation and toxic chemicals affirm anything. It appears to make things worse. pic.twitter.com/KnfHcGRTxz — Mimzy Borogroves No DM’s (@MBorogroves) May 5, 2024

What the researchers found is that “[i]ndividuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not.”

Of the patients who’d transitioned, a whopping 3.5 percent were later treated for suicide attempts. Conversely, only a paltry 0.3 percent of non-transitioned parents reported a suicide attempt.

The study’s findings sharply contrast the Biden administration’s claim that transgender surgery prevents suicide versus promoting it.

“Research demonstrates that gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents,” a handout from the Biden HHS reads.

“Because gender-affirming care encompasses many facets of healthcare needs and support, it has been shown to increase positive outcomes for transgender and nonbinary children and adolescents,” it continues.”

But this clearly isn’t true.

Responding to the latest study, DailyWire+ host Dr. Jordan B. Peterson slammed President Joe Biden and also Canadian Prime Minister Justin Trudeau for promoting transgender surgery.

“12x the suicide rate post ‘gender affirming’ surgery,” he wrote in a tweet. “The butchers and liars were murderously wrong.”

“The Cass report indicated this. Canada and the US are still enabling this. That’s you @POTUS and @JustinTrudeau and it is utterly barbarous and inexcusable. Putting children to the knife. ‘Follow the science,’ gentlemen,” he added.

12x the suicide rate post “gender affirming” surgery The butchers and liars were murderously wrong The Cass report indicated this Canada and the US are still enabling this That’s you @POTUS and @JustinTrudeau and it is utterly barbarous and inexcusable Putting children to the… — Dr Jordan B Peterson (@jordanbpeterson) May 16, 2024

Responding to Peterson’s tweet, many expressed agreement.

Psychiatric patients need treatment not surgery, it not the 1940’s. — 3percenter (@David61780271) May 16, 2024

The people who pushed this ideology onto others – especially children – need to be behind bars. — Richard (@RedWallPleb) May 16, 2024

30 years from now after the dust settles it will be impossible to find a supporter of this. People are keeping receipts. There will be no amnesty. — Furious_George (@furious15074) May 16, 2024

Anyone involved in the manipulation, mutilation and sterilization of children should be arrested and prosecuted to the fullest extent of the law! To prey on children when they are at their most vulnerable is beyond contemptible! Why?? — Judy (@Judy1732243) May 17, 2024

The gender identity gang lie. They lie about everything. It is a lie to claim a person can change their sex. It is a lie that puberty blockers are reversible. It is a lie that surgery can transition a person. Lie after lie after lie. — Kirralie Smith (@KirralieS) May 16, 2024

The release of the study last month came around the same time that Dr. Hilary Cass, one of England’s top pediatricians, released her own damning report about transgender surgery.

“Her final report, published last month, concluded that the evidence supporting the use of puberty-blocking drugs and other hormonal medications in adolescents was ‘remarkably weak,'” according to The New York Times.

On her recommendation, the U.K.’s National Health Service stopped prescribing puberty blockers outside of clinical trials. Cass also recommended that testosterone and estrogen only be prescribed with “extreme caution.”

Meanwhile, last year a study out of Denmark reportedly found that people who identify as transgender boast a suicide death rate 3.5 times higher than those who don’t.

Transgender people in Denmark have a significantly higher risk of suicide than other groups, an analysis of nearly seven million people over the last four decades found. The study is the first in the world to analyze national suicide data for this group. https://t.co/VH0FTrmT4z pic.twitter.com/KKIhDHJfQk — Alix (@AlixG_2) June 28, 2023

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Sex reassignment surgery market in us size is set to grow by usd 125.78 mn from 2023-2027, increase in number of people opting for sex change surgeries in us to boost the market growth, technavio.

NEW YORK , May 17, 2024 /PRNewswire/ -- The global   sex reassignment surgery market in us    size is estimated to grow by USD 125.78 mn from 2023-2027, according to Technavio. The market is estimated to grow at a CAGR of  10.84%  during the forecast period.

For more insights on the forecast market size and historic data (2017 - 2021) -  Download Free sample report in minutes  

Key Market Trends Fueling Growth

The sex reassignment surgery market in the US has witnessed significant growth due to increased transgender visibility through social media and societal acceptance. Transgender individuals, particularly those transitioning, require comprehensive care, including fertility consultations for preservation and counseling for gender identity exploration. Various gender-affirming surgical procedures are available, such as orchiectomy, ovariectomy, vaginoplasty, chest masculinization surgery, and facial feminization surgery. Innovations continue in metoidioplasty, phalloplasty, and scrotoplasty. Medicare and Medicaid programs cover some of these procedures for transgender beneficiaries. Hospitals like Mount Sinai and clinics such as the Transgender Surgery Institute offer gender-affirming surgeries.

Market Challenges

The sex reassignment surgery market in the US faces challenges due to potential complications from procedures such as facial, top, and bottom surgeries for transgender males and females. Adverse effects include vaginal closure, skin graft rejection, and urinary issues. Rare cases may result in major complications. Common risks include bleeding, infection, and anesthetic side effects. Other gender-affirming care, like hormone therapy and mental health support, are essential components of the transgender population's overall health and well-being. The public health challenge of gender dysphoria requires equitable access to surgical techniques and medical services, including chest surgery, chin augmentation, and facial feminization surgery. Technological innovation and societal stigma also impact the growth of this market.

Research report provides comprehensive data on impact of trend, driver and challenges -   Buy Report

Segment Overview 

This sex reassignment surgery market in US report extensively covers market segmentation by

1.1 Male to female

1.2 Female to male

2.1 Hospitals

2.2 Clinics

3.1 North America

1.1 Male to female-  The Sex Reassignment Surgery (SRS) market in the US is primarily segmented into two categories: transgender males and transgender females, each with unique requirements for gender dysphoria transition. Hospitals specializing in gender affirmation surgeries offer various procedures for these populations, including hysterectomy, salpingo-oophorectomy, orchiectomy, ovariectomy, and mastectomy for transgender females, and phalloplasty, scrotoplasty, and chest masculinization surgery for transgender males. The young transgender population also seeks SRS, with procedures such as reduction thyrochondroplasty for voice feminization and vaginoplasty for neo-vagina creation. The Obamacare legislation and Medicaid program have expanded coverage for transgender beneficiaries, increasing access to gender-affirming care. Key surgical procedures include hysterectomy, orchiectomy, and vaginoplasty, while augmentation mammoplasty, breast reduction, and facial feminization surgery cater to the transfeminine population. Transgender issues continue to evolve, with ongoing research and development in SRS techniques.

For more information on market segmentation with geographical analysis including forecast (2023-2027) and historic data (2017 - 2021)  - Download a Sample Report

Research Analysis

The Sex Reassignment Surgery (SRS) market in the US has witnessed significant growth, driven by the increasing number of transgender individuals seeking gender dysphoria treatment. This cohort includes transgender males and females, particularly among the young population. Gender dysphoria transition often involves self-identified gender exploration and the pursuit of gender-affirming interventions such as Gender-confirming surgeries and hormone therapy. Gender-affirming surgeries encompass various procedures, including genital reconstructive procedures for transgender males and chest surgery (mastectomy) and facial feminization surgery for transgender females. Clinicians play a crucial role in providing mental health support and guiding patients through the temporal trends of SRS. Hormone therapy and gender-confirming surgeries have become increasingly accepted medical interventions for transgender individuals. The National Inpatient Sample provides valuable insights into the utilization and outcomes of these procedures. Overall, the SRS market continues to expand, reflecting the growing recognition and acceptance of transgender individuals and their unique healthcare needs.

Market Research Overview

The Sex Reassignment Surgery (SRS) market in the US has been witnessing significant growth due to increasing acceptance and recognition of gender diversity. The market encompasses various procedures such as orchiectomy, vaginoplasty, and phalloplasty, among others. These surgeries aim to help individuals align their physical identity with their gender identity. The market is driven by factors like growing awareness and acceptance of transgender and gender non-conforming individuals, advancements in surgical techniques, and improved access to healthcare. The market also faces challenges like high costs, lack of insurance coverage, and stigma associated with gender diversity. The market is segmented based on procedures, regions, and end-users. The future outlook of the market is promising with increasing acceptance and recognition of gender diversity and advancements in surgical techniques.

Table of Contents:

1 Executive Summary 2 Market Landscape 3 Market Sizing 4 Historic Market Size 5 Five Forces Analysis 6 Market Segmentation

7 Customer Landscape 8 Geographic Landscape 9 Drivers, Challenges, and Trends 10 Company Landscape 11 Company Analysis 12 Appendix

About Technavio

Technavio is a leading global technology research and advisory company. Their research and analysis focuses on emerging market trends and provides actionable insights to help businesses identify market opportunities and develop effective strategies to optimize their market positions.

With over 500 specialized analysts, Technavio's report library consists of more than 17,000 reports and counting, covering 800 technologies, spanning across 50 countries. Their client base consists of enterprises of all sizes, including more than 100 Fortune 500 companies. This growing client base relies on Technavio's comprehensive coverage, extensive research, and actionable market insights to identify opportunities in existing and potential markets and assess their competitive positions within changing market scenarios.

Technavio Research Jesse Maida Media & Marketing Executive US: +1 844 364 1100 UK: +44 203 893 3200 Email:  [email protected] Website:  www.technavio.com/

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SOURCE Technavio