gender reassignment surgery psychological effects

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.

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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.

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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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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

Study Finds Long-Term Mental Health Benefits of Gender-Affirming Surgery for Transgender Individuals

• October 14, 2019

UPDATE: August 1, 2020

The American Journal of Psychiatry has published an erratum notice after conducting a statistical analysis that was prompted by letters questioning the methodology of “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study.” The erratum explains why the study’s conclusion “that the longitudinal association between gender-affirming surgery and lower use of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them” is too strong.

For details, read the erratum , author’s response , and the study with a post publication addendum .

Washington – For transgender individuals, gender-affirming surgery can lead to long-term mental health benefits, according to new research published online today in The American Journal of Psychiatry. The study found that among transgender individuals with gender incongruence, undergoing gender-affirming surgery was significantly associated with a decrease in mental health treatment over time.

Researchers Richard Branstrom, Ph.D., and John E. Pachankis, Ph.D., with the Yale School of Public Health, New Haven, Connecticut, used the Swedish Total Population Register to identify more than 2.500 individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015. Among individuals with gender incongruence, just more than 70% had received hormone treatment and nearly half (48%) had undergone gender-affirming surgical treatment during the 10-year follow-up period. Nearly all (97%) of those who had undergone surgery also received hormone treatment. Less than one-third had received neither treatment.

They analyzed mental health treatment in 2015 in relation to the length of time since gender-affirming hormone and surgical treatment, including distinguishing the potentially interrelated effects of the two treatments. The mental health measures included health care visits for mood and anxiety disorder, antidepressant and anti-anxiety prescriptions, and hospitalization after a suicide attempt.

Increased time since last gender-affirming surgery was associated with reduced likelihood of use of mental health treatment. The study found the odds of receiving mental health treatment were reduced by 8% for every year since receiving gender-affirming surgery over the 10-year follow-up period. They did not find the same association for hormone treatment.

The study also found that compared with the general population, transgender individuals with a gender incongruence were

• about six times as likely to have had a mood or anxiety disorder health care visit;
• more than three times as likely to have received prescriptions for antidepressants and anti-anxiety medication; and
• more than six times as likely to have been hospitalized after a suicide attempt.

Despite the reduced mental health treatment use after gender-affirming surgery, treatment use among transgender individuals continued to exceed that of the general population.

The authors conclude that “In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.”

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• Introduction
• Conclusions
• Article Information

Includes 2015 US Transgender Survey respondents who indicated they desired and either had or had not undergone at least 1 type of gender-affirming surgery. Respondents were presented with 1 of 2 lists of gender-affirming surgeries based on their self-reported sex assigned at birth.

• Legislation to Criminalize Gender-Affirming Medical Care for Transgender Youth JAMA Viewpoint June 8, 2021 This Viewpoint describes legislation aiming to criminalize medical care for transgender youth and explains why these bills are harmful and potentially unlawful. Jack L. Turban, MD, MHS; Katherine L. Kraschel, JD; I. Glenn Cohen, JD
• Gender-Affirming Surgeries and Improved Psychosocial Health Outcomes JAMA Surgery Invited Commentary July 1, 2021 Andrew A. Marano, MD; Matthew R. Louis, MD; Devin Coon, MD, MSE

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Almazan AN , Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021;156(7):611–618. doi:10.1001/jamasurg.2021.0952

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Association Between Gender-Affirming Surgeries and Mental Health Outcomes

• 1 Harvard Medical School, Boston, Massachusetts
• 2 Harvard T. H. Chan School of Public Health, Boston, Massachusetts
• 3 The Fenway Institute, Fenway Health, Boston, Massachusetts
• 4 Department of Psychiatry, Massachusetts General Hospital, Boston
• Invited Commentary Gender-Affirming Surgeries and Improved Psychosocial Health Outcomes Andrew A. Marano, MD; Matthew R. Louis, MD; Devin Coon, MD, MSE JAMA Surgery
• Viewpoint Legislation to Criminalize Gender-Affirming Medical Care for Transgender Youth Jack L. Turban, MD, MHS; Katherine L. Kraschel, JD; I. Glenn Cohen, JD JAMA

Question   Are gender-affirming surgeries associated with better mental health outcomes among transgender and gender diverse (TGD) people?

Findings   In this secondary analysis of the 2015 US Transgender Survey (n = 27 715), TGD people with a history of gender-affirming surgery had significantly lower odds of past-month psychological distress, past-year tobacco smoking, and past-year suicidal ideation compared with TGD people with no history of gender-affirming surgery.

Meaning   These findings support the provision of gender-affirming surgeries for TGD people who seek them.

Importance   Requests for gender-affirming surgeries are rapidly increasing among transgender and gender diverse (TGD) people. However, there is limited evidence regarding the mental health benefits of these surgeries.

Objective   To evaluate associations between gender-affirming surgeries and mental health outcomes, including psychological distress, substance use, and suicide risk.

Design, Setting, and Participants   In this study, we performed a secondary analysis of data from the 2015 US Transgender Survey, the largest existing data set containing comprehensive information on the surgical and mental health experiences of TGD people. The survey was conducted across 50 states, Washington, DC, US territories, and US military bases abroad . A total of 27 715 TGD adults took the US Transgender Survey, which was disseminated by community-based outreach from August 19, 2015, to September 21, 2015. Data were analyzed between November 1, 2020, and January 3, 2021.

Exposures   The exposure group included respondents who endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses. The comparison group included respondents who endorsed a desire for 1 or more types of gender-affirming surgery but denied undergoing any gender-affirming surgeries.

Main Outcomes and Measures   Endorsement of past-month severe psychological distress (score of ≥13 on Kessler Psychological Distress Scale), past-month binge alcohol use, past-year tobacco smoking, and past-year suicidal ideation or suicide attempt.

Results   Of the 27 715 respondents, 3559 (12.8%) endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses, while 16 401 (59.2%) endorsed a desire to undergo 1 or more types of gender-affirming surgery but denied undergoing any of these. Of the respondents in this study sample, 16 182 (81.1%) were between the ages of 18 and 44 years, 16 386 (82.1%) identified as White, 7751 (38.8%) identified as transgender women, 6489 (32.5%) identified as transgender men, and 5300 (26.6%) identified as nonbinary. After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing 1 or more types of gender-affirming surgery was associated with lower past-month psychological distress (adjusted odds ratio [aOR], 0.58; 95% CI, 0.50-0.67; P  < .001), past-year smoking (aOR, 0.65; 95% CI, 0.57-0.75; P  < .001), and past-year suicidal ideation (aOR, 0.56; 95% CI, 0.50-0.64; P  < .001).

Conclusions and Relevance   This study demonstrates an association between gender-affirming surgery and improved mental health outcomes. These results contribute new evidence to support the provision of gender-affirming surgical care for TGD people.

Transgender and gender diverse (TGD) people experience a disproportionate burden of mental health problems compared with the general population. 1 , 2 Prior studies of mental health among TGD people have demonstrated a 41% lifetime prevalence of suicide attempts, 2 7% to 61% lifetime prevalence of binge drinking, 3 and a 33% prevalence of tobacco use. 4 Increased adverse mental health outcomes among TGD people are likely attributable to stigma, discrimination, pathologization, economic marginalization, violence, and dysphoria associated with an incongruence between gender identity and societal expectations based on one’s sex assigned at birth. 5

According to Standards of Care published by the World Professional Association for Transgender Health, gender-affirming surgery is a medically necessary treatment to alleviate psychological distress for many TGD people. 6 The term gender-affirming surgery refers to any surgical procedures offered to affirm the gender identities of TGD people. The process of surgical gender affirmation is individually tailored because not all TGD people desire or access these procedures. 7 In the largest survey of the TGD community to our knowledge to date, 25% of respondents reported undergoing some type of gender-affirming surgery. 8

As a result of professional recommendations, insurance nondiscrimination laws, and expansion of dedicated transgender health practices, demand for gender-affirming surgery is steadily rising. 9 In the United States, incidence of gender-affirming surgeries has increased annually since 2000. 10 Despite growing demand for and access to gender-affirming surgery, there is a paucity of high-quality evidence regarding its effects on mental health outcomes among TGD people.

Existing evidence on the association between gender-affirming surgeries and mental health outcomes is largely derived from small-sample, cross-sectional, and uncontrolled studies. 1 , 11 , 12 A seminal 1998 review of the experiences of more than 2000 TGD people from 79 predominantly uncontrolled follow-up studies demonstrated qualitative improvement in psychosocial outcomes following gender-affirming surgery. 11 Attempts since then to empirically demonstrate mental health benefits from gender-affirming surgery have generated mixed results. A meta-analysis of 1833 TGD people across 28 studies concluded that studies offered “low-quality evidence” for positive mental health benefits from surgical gender affirmation. 12 The largest existing study on this subject to our knowledge, 13 a total population study including 2679 people diagnosed as having gender incongruence in Sweden, demonstrated a longitudinal association between gender-affirming surgery and reduced mental health treatment utilization. 13 However, a 2020 published correction of this study 14 demonstrated no mental health benefit from gender-affirming surgery after comparison with a control group of TGD people who had not yet undergone surgery. Mental health effects of gender-affirming surgery thus remain controversial.

Given the increasing incidence of surgical gender affirmation among TGD people, there is a significant need for clarification of the mental health benefits of gender-affirming surgery. In this article, we present the largest study to our knowledge to date on the association between gender-affirming surgeries and mental health outcomes. Using the 2015 US Transgender Survey, the largest existing data set on surgical and mental health experiences of TGD people, we investigate the hypothesis that gender-affirming surgeries are associated with improved mental health outcomes, including psychological distress, substance use, and suicidality.

In this study, we performed a secondary analysis of the 2015 US Transgender Survey (USTS). 8 This investigation is reported using Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guidelines.

Quiz Ref ID The 2015 USTS was a cross-sectional, nonprobability sample of responses from 27 715 TGD adults from 50 US states, Washington, DC, US territories, and US military bases abroad. The survey was developed by researchers, advocates, people with lived experience, and subject experts over the course of a year. The final survey contained 324 possible questions with 32 domains addressing subjects including health and health care access. It was disseminated by community-based outreach and administered online from August 19, 2015, to September 21, 2015. The USTS protocol was approved by the University of California, Los Angeles institutional review board. 8 The protocol for the present study was reviewed by the Fenway Institute institutional review board and did not meet criteria for human subjects research. For this reason, consent was not obtained.

Quiz Ref ID Five binary mental health outcomes were examined, including endorsement or denial of the following: (1) past-month severe psychological distress (score on the Kessler Psychological Distress Scale meeting the previously validated threshold of ≥13), 15 (2) past-month binge alcohol use (≥5 alcoholic drinks on one occasion), (3) past-year tobacco smoking, (4) past-year suicidal ideation, and (5) past-year suicide attempt.

The exposure group included respondents who endorsed a history of gender-affirming surgery, defined as undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting responses to the USTS. Respondents were asked about their experiences with gender-affirming surgeries through the question, “Have you had or do you want any of the health care listed below for gender transition?” Respondents were presented with 1 of 2 lists of gender-affirming surgeries based on their self-reported sex assigned at birth. For each surgery, respondents were able to indicate one of the following answers: “Have had it,” “Want it some day,” “Not sure if I want this,” or “Do not want this.” Respondents were included in the exposure group if they answered “Have had it” to 1 or more of the following types of gender-affirming procedures: breast augmentation, orchiectomy, vaginoplasty/labiaplasty, trachea shave, facial feminization surgery, or voice surgery. Respondents were also included in the exposure group if they answered “Have had it” to one or more of the following types of gender-affirming procedures: chest surgery, hysterectomy, clitoral release/metoidioplasty/centurion procedure, or phalloplasty.

In this study, outcomes of interest included mental health symptoms in the year prior to taking the USTS. To ensure that exposure to gender-affirming surgeries temporally preceded all outcomes of interest, respondents were included in the exposure group if they had received their first gender-affirming surgery at least 2 years prior to submitting responses to the USTS. For each respondent with a history of gender-affirming surgery, the number of years since their first surgery was calculated by subtracting age at first surgery from current age.

The control group included respondents who desired gender-affirming surgeries but had not yet received any. Respondents were included in this group if they answered “Want it some day” for at least 1 of the aforementioned gender-affirming procedures but did not answer “Have had it” for any of them. We excluded participants who did not report desire for any gender-affirming surgeries.

The following sociodemographic covariates were examined: age (18-44 years, 45-64 years, and ≥65 years), education level (less than high school or high school graduate up to associate degree, bachelor degree, or higher), employment status (employed, unemployed, or out of labor force), gender identity (transgender woman, transgender man, nonbinary, or cross-dresser), health insurance status (uninsured or insured), household income (<$25 000, $25 000-$99 999, or ≥$100 000), race (Alaska Native/American Indian, Asian/Pacific Islander, Black/African American, Latinx/Hispanic, other/biracial/multiracial, or White), sex assigned at birth (female or male), and sexual orientation (asexual, lesbian/gay/bisexual, or heterosexual).

Family rejection was included as a covariate and was defined by the USTS as history of any of the following experiences with a family member owing to the respondent’s gender identity: ending the relationship, physical violence, being forced out of their home, being prevented from wearing desired gender-concordant clothing, and exposure to gender identity conversion efforts. Lifetime exposures to other types of gender-affirming care were also examined, including gender-affirming counseling, pubertal suppression, and hormone therapy. Given the possibility that any of these covariates could confound the relationship between gender-affirming surgeries and mental health outcomes, all covariates were included in the final multivariable models.

All analyses were conducted using Stata, version 16.1 (StataCorp). Unweighted descriptive statistics for exposure and control groups were calculated and are presented as frequencies and percentages.

Multivariable logistic regression models adjusted for all covariates were generated to examine whether undergoing gender-affirming surgery is associated with each of the examined mental health outcomes. 16 , 17 To account for the survey’s nonprobability sampling, all models incorporated survey weights to correct sampling biases related to age and race/ethnicity. Adjusted odds ratios (aORs), 95% CIs, and 2-sided P values are reported.

We performed a post hoc analysis to determine whether associations between gender-affirming surgeries and mental health outcomes differ based on the degree of surgical affirmation. The exposure variable was recoded as 3 categories: those who received all desired surgeries, some desired surgeries, and no desired surgeries. Because the USTS did not collect information on timing of each respondent’s last surgery, respondents for this post hoc analysis could not be excluded to ensure that all exposures temporally preceded mental health outcomes. The recoded 3-category exposure variable was substituted into 5 additional multivariable logistic regression models, adjusted for all aforementioned covariates.

Owing to concerns that baseline mental health status may confound associations between gender-affirming surgery and mental health outcomes, we conducted an additional post hoc analysis to determine whether lifetime mental health measures were associated with exposure to gender-affirming surgeries. We did not incorporate these measures into the primary models due to collinearity. Four separate post hoc models, adjusted for all aforementioned covariates, regressed exposure to gender-affirming surgeries against lifetime suicidal ideation, lifetime suicide attempts, lifetime alcohol use, and lifetime smoking.

To account for multiple hypothesis testing, a Bonferroni correction was applied to adjust for 19 total tests. A P value of less than .002 was used as the corrected threshold for statistical significance.

Less than 2% of the study sample had missing data for exposure and outcome variables, and less than 9% of the study sample had missing data for any covariates. Given that these are acceptably low levels of missingness, 18 respondents with missing data were excluded without compensatory methods.

Of the 27 715 respondents, 3559 (12.8%) endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses, while 16 401 respondents (59.2%) endorsed a desire to undergo 1 or more types of gender-affirming surgery but denied undergoing any of these.

Compared with the control group, the exposure group had higher percentages of respondents who were older, employed, more educated, endorsed family rejection, reported having health insurance, and reported higher household income. Respondents in the exposure group were more likely to endorse a history of gender-affirming counseling, pubertal suppression, and hormone therapy ( Table 1 ).

For each surgical procedure, the percentage of people who desired it was higher than the percentage of people who endorsed undergoing it ( Figure 1 ). For every adverse mental health outcome, the percentage of respondents who endorsed it was lower in the exposure group than in the control group ( Figure 2 ).

Quiz Ref ID After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing 1 or more types of gender-affirming surgery was associated with lower past-month psychological distress (aOR, 0.58; 95% CI, 0.50-0.67; P  < .001), past-year smoking (aOR, 0.65; 95% CI, 0.57-0.75; P  < .001), and past-year suicidal ideation (aOR, 0.56; 95% CI, 0.50-0.64; P  < .001). After Bonferroni correction, there was no statistically significant association between gender-affirming surgeries and past-month binge alcohol use or past-year suicide attempts ( Table 2 ).

Quiz Ref ID In the post hoc analysis stratifying by degree of surgical affirmation, 16 401 respondents were in the reference group who received no desired surgeries. Respondents who had undergone all desired surgeries (n = 2448) had significant reductions in the odds of each adverse mental health outcome, and these reductions were more profound than those among respondents who had received only some desired surgeries (n = 3311) ( Table 3 ) .

Quiz Ref ID Measures of lifetime mental health were not associated with exposure to gender-affirming surgeries. After adjustment for all aforementioned covariates, undergoing gender-affirming surgery was not associated with lifetime suicidal ideation (aOR, 1.00; 95% CI, 0.85-1.20; P  = .92), lifetime suicide attempts (aOR, 1.16; 95% CI, 1.01-1.34; P  = .04), lifetime alcohol use (aOR, 1.00; 95% CI, 0.99-1.01; P  = .96), or lifetime smoking (aOR, 1.00; 95% CI, 1.00-1.01; P  = .34).

To our knowledge, this is the first large-scale, controlled study to demonstrate an association between gender-affirming surgery and improved mental health outcomes. In this study, we demonstrate that undergoing gender-affirming surgery is associated with decreased odds of past-month severe psychological distress, past-year smoking, and past-year suicidal ideation. The post hoc analysis stratifying by degree of surgical affirmation demonstrates that TGD people who underwent all desired surgeries had significantly lower odds of all adverse mental health outcomes, and these benefits were stronger than among TGD people who only received some desired surgeries.

The observed associations between gender-affirming surgery, psychological distress, and suicide risk reinforce previous small-sample studies suggesting that gender-affirming surgery improves mental health and quality of life among TGD people. 1 , 12 Our findings also reflect evidence from qualitative studies indicating perceived mental health benefits of gender-affirming surgeries among TGD people. 19 - 21 In our primary analysis, although gender-affirming surgery was associated with lower odds of past-year suicidal ideation, there was no statistically significant association between gender-affirming surgeries and past-year suicide attempts. However, in a post hoc analysis respondents who underwent all desired gender-affirming surgeries had significantly lower odds of past-year suicide attempts.

The association observed between gender-affirming surgeries and reduction in substance use behaviors is consistent with previous studies involving small community samples that demonstrated associations between gender-affirming medical care and lower odds of high-risk substance use. 22 , 23 In the primary analysis, undergoing gender-affirming surgery was not significantly associated with past-month binge alcohol use. This may be consistent with evidence that after adjustment for sociodemographic factors, gender minority identity itself does not predict high-risk alcohol use. 24 However, in a post hoc analysis, respondents who underwent all desired gender-affirming surgeries had significantly lower odds of past-month binge alcohol use.

This investigation offers evidence to support the clinical practice of gender-affirming surgery. Guidelines for provision of gender-affirming medical and surgical care have historically been challenged based on a limited evidence base. The American Psychiatric Association has previously concluded that the quality of evidence for treatment of gender dysphoria is low, and consequently, recommendations regarding gender-affirming care have been driven by clinical consensus where empirical evidence is lacking. 25 This study offers new data that substantiate the current clinical consensus by expanding the evidence base in support of gender-affirming surgical care.

The observed mental health benefits of gender-affirming surgeries in this study highlight the importance of policies that facilitate access to surgical gender affirmation. In the present study, the percentages of people who had undergone each gender-affirming surgical procedure were substantially lower than the percentages of people who desired them, suggesting significant barriers to accessing gender-affirming surgeries. State-level prohibitions against insurance exclusions for gender-affirming care have been associated with more extensive coverage of gender-affirming surgical procedures. 26 In light of this study’s results, such policies may be of even greater public health interest. US federal policies related to gender-affirming care have included a recent reversal of Affordable Care Act insurance protections for gender affirmation and the continued prohibition of Veterans Affairs funding allocation for gender-affirming surgeries. 27 , 28 Formulation of evidence-based policies for the financing of gender-affirming surgery will be crucial for advancing the health and well-being of TGD communities.

This study’s strengths include aspects of its design that address prior limitations in the existing literature on this subject. Multiple meta-analyses of studies examining the association between gender-affirming surgeries and mental health outcomes have demonstrated that much of the existing literature consists of evidence derived with small sample sizes, lack of control groups, and lack of adjustment for other kinds of gender-affirming care. 12 , 29 Our study is responsive to these methodologic concerns.

First, we used the largest existing data set containing information on the surgical and mental health experiences of TGD people. Second, this is, to our knowledge, the first large-scale study on this subject to use the ideal control group to examine associations between gender-affirming surgeries and mental health outcomes: individuals who desire gender-affirming surgery but have not yet received it. Experts have cautioned against using comparison groups that conflate TGD people who did not undergo gender-affirming surgery because they were waiting for it with TGD people not seeking it in the first place. Inability to differentiate these 2 groups likely contributed to the lack of significant mental health benefit observed in the 2019 large-scale study on this subject. 13 , 30

Third, although this survey-based investigation uses a cross-sectional study design, we constructed an exposure group that includes only individuals exposed to their first gender-affirming surgery prior to the window of assessment for any adverse mental health outcomes. Thus, we ensured that our exposure temporally preceded our outcomes, allowing us to better understand the direction of observed associations. These exclusions could not be performed in our post hoc analysis stratifying by degree of surgical affirmation, and that analysis should therefore be interpreted with caution.

Fourth, our data set allowed us to control for previous experiences of gender-affirming counseling, pubertal suppression, and hormone therapy. Consequently, this study is, to our knowledge, the first large-scale investigation to ascertain the mental health benefits of gender-affirming surgeries independent of other common forms of gender-affirming health care.

Our study has several limitations. The nonprobability sampling of the USTS may limit generalizability. All measures are self-reported and may be subject to response bias. Furthermore, the USTS only offers data on experiences with 10 specific types of gender-affirming surgeries and does not capture the full range of procedures that constitute gender-affirming surgery. Lastly, because this is an observational study, it may be subject to unmeasured confounding. Much of the literature on mental health benefits of gender-affirming surgery has been complicated by inability to adjust for a key confounder: baseline mental health status. Our post hoc analysis demonstrates that lifetime suicidality and substance use behaviors are not associated with the exposure variable in this sample. Therefore, prior mental health factors do not appear to confound associations between gender-affirming surgery and subsequent mental health outcomes in our study. There may nevertheless be other types of mental health problems not captured in the USTS that confound these associations. These limitations highlight the need for larger probability-based surveys with TGD communities, more consistent gender identity data collection across health care systems, and more comprehensive baseline health data collection with TGD populations.

In this article, we present the largest study to our knowledge to date on associations between gender-affirming surgeries and mental health outcomes. Our results demonstrate that undergoing gender-affirming surgery is associated with improved past-month severe psychological distress, past-year smoking, and past-year suicidal ideation. Our findings offer empirical evidence to support provision of gender-affirming surgical care for TGD people who seek it. Furthermore, this study provides evidence to support policies that expand and protect access to gender-affirming surgical care for TGD communities.

Corresponding Author: Anthony N. Almazan, BA, Harvard Medical School, 25 Shattuck St, Boston, MA 02215 ( [email protected] ).

Accepted for Publication: February 5, 2021.

Published Online: April 28, 2021. doi:10.1001/jamasurg.2021.0952

Author Contributions: Mr Almazan 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: All authors.

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

Drafting of the manuscript: All authors.

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

Statistical analysis: Almazan.

Obtained funding: Keuroghlian.

Administrative, technical, or material support: Keuroghlian.

Supervision: Keuroghlian.

Conflict of Interest Disclosures: Dr Keuroghlian reported grants from Patient-Centered Outcomes Research Institute Contract AD-2017C1-6569 (PI: Sari L. Reisner) during the conduct of the study; in addition, Dr Keuroghlian stands to receive future royalties as editor of a forthcoming McGraw-Hill Education textbook on transgender and gender diverse care. No other disclosures were reported.

Funding/Support: This work was supported by contract AD-2017C1-6569 from the Patient-Centered Outcomes Research Institute (PI: Dr Sari L. Reisner).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the National Center for Transgender Equality for granting us access to the data from the 2015 US Transgender Survey.

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The psychological challenges of gender reassignment surgery

July/August 2007, Vol 38, No. 7

Print version: page 53

Surgery and hormonal therapy are increasingly common treatments for gender dysphoria, but the prejudice and discrimination transgender individuals face post-transition can cause significant psychological distress, says Marci Bowers, MD, a surgeon who performs gender reassignment surgery in Trinidad, Colo., and is herself transgender.

Post-change, many men and women deal with rancorous divorces, custody battles, job loss and rejection by family members, she has found. Some even commit suicide, continues Bowers, who will speak about the psychological impact of transgendersurgery at APA's 2007 Annual Convention.

"It's a wonder that anyone transitions-the penalties are so severe," she says.

Bowers wants to help dispel the myths and misperceptions surrounding transgender surgery-among them that transitioning individuals are really gay men or lesbians in denial or that they are mentally ill.

"Because dysphoria is currently listed as a psychological disorder, transgender [people] are assumed to be mentally ill," she explains. "This doesn't allow them to be treated equally, no matter how visually compelling the change is."

This stigma can have far-reaching psychological effects, Bowers says. "The transition provides great barriers to intimacy, and for a person's psychological well-being, intimacy is very important."

Psychologists can help transgender people overcome such barriers as therapists and also by researching and raising awareness about the social and economic barriers transgender people face.

--L. Meyers

Letters to the Editor

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The Gender Reassignment Controversy

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

Posted March 16, 2018 | Reviewed by Ekua Hagan

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

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

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

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

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

The Money Perspective

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

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

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

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

Adult Reassignment Surgery Motivation

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

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

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

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

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

Adult Reassignment Results

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

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

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

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

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

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

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

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

Aspirational Surgery

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

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

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

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

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

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

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

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

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• 28 May 2024

Heed lessons from past studies involving transgender people: first, do no harm

• Mathilde Kennis 0 ,
• Robin Staicu 1 ,
• Marieke Dewitte 2 ,
• Guy T’Sjoen 3 ,
• Alexander T. Sack 4 &
• Felix Duecker 5

Mathilde Kennis is a researcher in cognitive neuroscience and clinical psychological science at Maastricht University, the Netherlands.

You can also search for this author in PubMed   Google Scholar

Robin Staicu is a neuroscientist and specialist in diversity, equity and inclusion at Maastricht University, the Netherlands.

Marieke Dewitte is a sexologist and assistant professor in clinical psychological science at Maastricht University, the Netherlands.

Guy T’Sjoen is a clinical endocrinologist and professor in endocrinology at Ghent University Hospital, Belgium, the medical coordinator of the Centre for Sexology and Gender at Ghent University Hospital, and one of the founders of the European Professional Association for Transgender Health.

Alexander T. Sack is a professor in cognitive neuroscience at Maastricht University, the Netherlands.

Felix Duecker is an assistant professor in cognitive neuroscience at Maastricht University, the Netherlands.

You have full access to this article via your institution.

Over the past few decades, neuroscientists, endocrinologists, geneticists and social scientists have conducted numerous studies involving transgender people, meaning those whose gender identity does not conform to that typically associated with the sex to which they were assigned at birth. Justifications for doing such research have shifted over the years and, today, investigators are increasingly focused on assessments of transgender people’s mental health or the impact of hormone therapies.

But such work raises challenges. Despite researchers’ best intentions, these studies can perpetuate stigmas and make it even harder for transgender people to access appropriate medical care.

Here we focus on neuroscientific approaches to the study of transgender identity to explore how investigators might navigate these concerns.

Brain scanning

In 1995, neuroscientists at the Netherlands Institute for Brain Research in Amsterdam published findings from a post-mortem study, which included six transgender individuals 1 . They found that the volume of part of the brain’s hypothalamus — called the bed nucleus of the stria terminalis, which tends to be larger in men than in women — corresponded to the gender identity of the transgender individuals, not to their sex assigned at birth. Although the data were only correlative, the researchers suggested that people identify as transgender because of changes in the brain that happen before birth — in other words, that someone can be born with a male-typical body and brain characteristics more typical of a female brain, and vice versa.

Sex and gender in science

Since it was published, the paper has been cited more than 1,000 times, and at least a dozen researchers have probed this theory and related ones using tools such as structural and functional magnetic resonance imaging (MRI).

Although the results of these analyses have been inconsistent, several ideas have nonetheless arisen about a neurobiological basis for gender dysphoria — the distress associated with a person’s gender identity not aligning with the sex they were assigned at birth. These include the ‘own-body perception’ theory 2 , which proposes that a reduced structural and functional connectivity between certain brain networks is responsible. (Previous work has associated these networks with brain regions thought to be involved in people’s ability to link their own body to their sense of self 3 .)

As analytical tools and methods advance, brain research is becoming more sophisticated. The number of neuroscientific studies that include transgender participants has increased considerably since 1991 (see ‘On the rise’).

Some neuroscientists are using functional MRI to study the effects of hormone therapy on brain structure 4 and to examine cognitive processes such as face perception 5 . Others are applying machine-learning techniques to establish whether features in brain scans of cis- and transgender people correlate with their gender identity 6 . Researchers are also trying to assess whether particular features identified in brain scans make it more likely that transgender individuals will benefit from gender-affirming hormone therapy 7 . And some are conducting ‘mega-analyses’ — pooling the brain scans of hundreds of participants — to identify brain characteristics that are specific to transgender people 8 .

Help or harm?

One concern arising from such studies is that neuroscientific findings related to transgender identity could make it even harder for some people to access medical treatment that could help them.

In countries or regions where gender-affirming medical treatment is available, individuals often need a diagnosis of ‘gender dysphoria’ or ‘gender incongruence’ to be eligible for hormone therapy or gender-affirming surgery, and to be reimbursed for such treatments. Results from brain scans could be included in the suite of measurements used to assess whether someone is experiencing gender dysphoria or incongruence.

Those in favour of such requirements argue that it is necessary to prevent people taking irreversible steps that they might regret. Hormonal therapy can have adverse effects on fertility, for instance 9 . However, many transgender people argue that whether someone can receive gender-affirming hormone therapy or other treatment shouldn’t depend on a health-care practitioner deciding that they experience ‘enough’ gender dysphoria to be eligible 10 . The current approach, combined with a shortage of specialists qualified to make such diagnoses, has been linked to long waiting lists. In the Netherlands, waiting times can be more than two years .

A second possibility is that neuroscientific findings related to transgender identity will fuel transphobic narratives 11 .

Take the debate on social media and other platforms about gendered public spaces in countries such as the United States , the United Kingdom and Brazil 12 . Some people argue that allowing transgender women to access infrastructure, such as public toilets or women’s prisons, threatens the safety of “real women” . Neuroscientific research is sometimes misused to bolster flawed claims about what ‘real’ means.

Moreover, such studies could exacerbate tensions between scientific and transgender communities.

Scientists are aiming to identify brain characteristics that are specific to transgender people. Credit: Alain Jocard/AFP/Getty

Although cis- and transgender researchers have taken steps to improve people’s understanding, there is a history of tension between the scientific and transgender communities 13 . In the late 1980s, for instance, a sexologist argued that trans women who are mainly attracted to women experience sexual arousal from their own expression of femininity. He described their feelings of gender dysphoria as resulting from paraphilia — a sexual interest in objects, situations or individuals that are atypical 14 . This theory has not held up under broader scientific scrutiny 15 , but it has become notorious in the transgender community and, from our discussions with transgender people and discussions by other groups 16 , it is clear that such studies have reduced transgender people’s trust in science.

How four transgender researchers are improving the health of their communities

In 2021, for example, a neuroimaging study with transgender participants was suspended in the United States after backlash from the transgender community. The study would have involved showing participants images of themselves wearing tight clothes, with the intention of triggering gender dysphoria — an experience that is associated with depression, anxiety, social isolation and an increased risk of suicide. The study’s researchers had acquired ethical approval from their research institute and obtained informed consent from the participants. Yet they had failed to anticipate how the transgender community would perceive their experimental procedure.

In 2022, to learn more about how transgender people view current neuroscientific approaches to the study of transgender identity, we conducted focus-group interviews that lasted for three hours with eight transgender participants — all of whom had differing levels of knowledge about the topic.

The group expressed concern that studies that look for a neurological basis to transgender identities could have a pathologizing effect. “I think questions of aetiology are just inherently wrong,” one participant said. “We don’t ask ‘Why is someone’s favourite colour blue?’. These are questions that come from wanting to pathologize.” Participants also agreed that a biological-determinist approach does not do justice to the complex and layered experience of identifying as transgender.

Decades of work aimed at establishing how science can benefit minority groups 17 suggest that neuroscientists and other scholars could take several steps to ensure they help rather than harm transgender, non-binary and intersex individuals and other people who don’t conform to narrow definitions around sex and gender. Indeed, the four actions that we lay out here are broadly applicable to any studies involving marginalized groups.

Establish an advisory board. Researchers who work with transgender participants should collaborate with an advisory board that ideally consists of transgender people and members of other groups with relevant perspectives, including those who have some understanding of the science in question. Funding agencies should support such initiatives, to help prevent further distrust being sown because of how studies are designed.

Set up multidisciplinary teams. Researchers trained in neuroscience will view phenomena such as transgender identity through a different lens from, say, those trained in psychology. To prevent the outcomes of neuroscientific and other studies being described and published in an overly deterministic and simplistic way 18 , research teams should include social scientists. Ideally, such collaborations would also include transgender researchers or others with diverse gender identities, because their input would help to prevent a cis-normative bias in study design and in the interpretation of results. Indeed, our own group has benefited from this diversity (one of us is transgender).

Prioritize research that is likely to improve people’s lives. Neuroscientists and others engaged in research involving transgender participants, non-binary people or individuals with diverse gender identities should prioritize research questions that are likely to enhance the health of these groups. Although the applications of basic research can be hard to predict, investigations into the neurobiological impacts of hormone treatment on the brain, for instance, could be more directly informative to health-care practitioners and transgender individuals than might investigations into the underlying bases of transgender identity.

Rethink how ethical approval is obtained. Ethical boards at universities typically consist of scientists with diverse backgrounds. But it is unrealistic to expect them to be educated on the sensitivities of every minority group, whether in relation to gender, religion, ethnicity or anything else. One way to address this problem is for ethical boards to require researchers to state what feedback and other information they have gathered through community engagement. A university’s ethical review committee could then evaluate whether the researchers have done enough to understand and address people’s concerns and sensitivities.

Our aim is not to halt scientific enquiry. But when it comes to transgender identity, knowledge cannot be pursued in isolation from the many societal factors that shape how that knowledge is received and acted on.

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Effects of adequacy of gender reassignment surgery on psychological adjustment: a follow-up of fourteen male-to-female patients

Affiliation.

• 1 Department of Psychiatry, Flinders University Medical School, Adelaide, South Australia.
• PMID: 2712690
• DOI: 10.1007/BF01543120

The relationship between the adequacy of surgical result and postoperative psychopathology was examined in 14 male-to-female transsexuals selected for the absence of preoperative psychopathology. Data indicated that the best predictors of postoperative psychopathology as rated on Hunt and Hampson's (1980) Standardized Rating Format were breast scarring, erectile urethral meatus, current social supports, family reaction, urinary incontinence, and need for extra surgery. Together, these accounted for 98% of the variance in postoperative psychopathology. These data suggest that factors which make it difficult for postoperative transsexuals to "pass" or which continue to remind them of their gender-reassigned status are associated with adjustment difficulties. Surgical results may be a major determinant of postoperative psychopathology.

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• A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals. Mate-Kole C, Freschi M, Robin A. Mate-Kole C, et al. Br J Psychiatry. 1990 Aug;157:261-4. doi: 10.1192/bjp.157.2.261. Br J Psychiatry. 1990. PMID: 2224377 Clinical Trial.
• [The transsexual after sex change. Evolution and prognosis]. Calanca A. Calanca A. Helv Chir Acta. 1991 Sep;58(3):257-60. Helv Chir Acta. 1991. PMID: 1769841 French.
• Transsexualism: a standardized psychosocial rating format for the evaluation of results of sex reassignment surgery. Hunt DD, Hampson JL. Hunt DD, et al. Arch Sex Behav. 1980 Jun;9(3):255-63. doi: 10.1007/BF01542251. Arch Sex Behav. 1980. PMID: 7396697
• [Male-to-female transsexualism. Sex reassignment surgery from a biopsychosocial perspective]. Baranyi A, Piber D, Rothenhäusler HB. Baranyi A, et al. Wien Med Wochenschr. 2009;159(21-22):548-57. doi: 10.1007/s10354-009-0693-5. Wien Med Wochenschr. 2009. PMID: 19997841 Review. German.
• Transsexualism: a review of etiology, diagnosis and treatment. Cohen-Kettenis PT, Gooren LJ. Cohen-Kettenis PT, et al. J Psychosom Res. 1999 Apr;46(4):315-33. doi: 10.1016/s0022-3999(98)00085-3. J Psychosom Res. 1999. PMID: 10340231 Review.
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• Satisfaction with male-to-female gender reassignment surgery. Hess J, Rossi Neto R, Panic L, Rübben H, Senf W. Hess J, et al. Dtsch Arztebl Int. 2014 Nov 21;111(47):795-801. doi: 10.3238/arztebl.2014.0795. Dtsch Arztebl Int. 2014. PMID: 25487762 Free PMC article.
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• v.82(4); November, 2015

Transsexual attractions and sexual reassignment surgery: Risks and potential risks

Transsexual issues and sexual reassignment surgery (SRS) are receiving a great deal of attention and support in the media, schools, and government. Given the early age at which youth seek treatment for transsexual attractions (TSA) and gender dysphoria and given the serious risks associated with such treatment, it is essential that family and youth be advised about these risks and alternative treatment options. Physicians and mental-health professionals have a professional responsibility to know and communicate the serious risks, in particular risk of suicide, that are associated with SRS; the spontaneous resolution of TSA in youth; the psychological conflicts that have been identified in such patients and in their parents; the successful treatment of conflicts associated TSA and the regrets of those who have been through SRS. SRS and gender theory are also viewed from the faith perspective of Pope Francis and Pope Emeritus Benedict XVI.

Lay summary : Transsexuals and sex-change operations are receiving a great deal of attention. Young people may seek treatment for transsexual attractions at an early age even though these attractions may go away on their own. Psychological conflicts have been identified in these patients and their parents and may be successfully treated. There are serious risks associated with sex change. They include the risk of depressive illness and suicide. Physicians and mental-health professionals should know these risks and the regrets of those who have been through sex-change operations. These patients and their families also should be informed of other treatment options.

Transsexual issues and sexual reassignment surgery are receiving a great deal of attention and support in the media, schools, government and in health professionals today.

Dr. Paul McHugh, former chairperson of the Department of Psychiatry at Johns Hopkins Hospital, has written that,

The idea that one's sex is fluid and a matter open to choice runs unquestioned through our culture and is reflected everywhere in the media, the theater, the classroom, and in many medical clinics. It has taken on cult-like features: its own special lingo, Internet chat rooms providing slick answers to new recruits, and clubs for easy access to dresses and styles supporting the sex change. It is doing much damage to families, adolescents, and children and should be confronted as an opinion without biological foundation wherever it emerges. ( McHugh 2015 )

Transsexual issues are creating a new controversy in our elementary and high schools today as a result of youth and their parents asserting a right to identify the sex of their child without regard to the biological and genetic realities. The parents and child may insist that the child's name be changed to one of the opposite sex and that the child be allowed to wear clothing of the opposite sex and use opposite-sex bathrooms.

These families are often preparing their children for sexual reassignment surgery (SRS) without being given the knowledge of the serious, documented risks associated with such surgery or other treatment options for gender dysphoria, referred to in the past as gender identity disorder (GID). Endocrinologists who are giving hormones to these youth, mental-health professionals who are affirming SRS surgery, and surgeons have a professional responsibility to understand these grave risks; and these patients also should be apprised of these risks.

An early study of these risks included one hundred patients seeking SRS, sixty-six of whom had surgery and 34 of whom did not ( Meyer and Reter 1979 ). The operated-upon groups were followed from the time of surgery, the unoperated-upon group from the time of initial interview at the Gender Identity Clinic at Johns Hopkins. Of those operated on, twenty-one had a trial period (taking hormones and working in the opposite-gender role) while the other thirteen had been well-established in the cross-gender role at the time of surgery but did not have a formal trial period. Follow-up was successful in fifty-two patients, of whom fifty consented to have their data published. Follow-up interviews covered three main areas: adaptation; family relationships and adaptational patterns at major life intervals; and fantasy, dreams, and sexual activity. 73–80 percent of the patients were male. Average follow-up for operated-upon patients was sixty-two months and twenty-five months for the unoperated-upon group.

Residential instability was similar in the groups (average of twenty months between moves in the operated-upon group pre-surgery, eighteen months post-surgery, and twelve months pre-contact and ten months post-contact in the unoperated-upon group). Job levels indicated a slight upward trend in both groups. Changes in psychiatric contacts were also similar in the two groups.

A third group was found that went elsewhere for surgery when this was not performed at Hopkins. Adjustment scores were improved in the surgery and unoperated-upon group to a similar extent, with no significant difference between the groups, but the group that sought surgery elsewhere did less well (although there was no statistical significance to the difference).

As stated by the authors, “At the most simple level, these data suggest that significant change in adjustment scores may be achieved either through surgery or through the passage of time in association with some contact and acceptance into an organized evaluation program” ( Meyer and Reter 1979 ). The conclusion was that SRS was not successful in treating this condition and led to the discontinuation of SRS at Johns Hopkins.

In spite of these early findings, and lack of contravening evidence that SRS conveyed any benefits compared with any unoperated-upon control groups, the practice of SRS has continued and has been extended into younger age groups. In a 2015, Boston study of 180 transsexual youth who had undergone SRS (106 female-to-male; 74 male-to-female), these youth had a twofold to threefold increased risk of psychiatric disorders, including depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment compared to a control group of youth ( Reisner et al. 2015 ).

(An important research study would be that of determining how many of these youth, and their parents or guardians, were informed about the psychiatric risks associated with the surgery which is described in the mental health literature and which should be known by the treating health professionals. Since the mean age at which youth presented for consideration for SRS surgery in the Boston study was age 9, providing this information in a way that the children would understand would be challenging but nonetheless could be done in regard to discussing suicide risks and successful alternative treatments for gender dysphoria. The primary childhood psychological conflicts that interfere with the appreciation of the goodness of a child's masculinity or femininity should be given.)

The largest study to date of the long-term psychological state of post-SRS persons was an analysis of over three hundred people who had undergone SRS in Sweden over the past thirty years. This 2011 study demonstrated that persons after sex reassignment, have considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population ( Dhejne et al. 2011 ).

In 2014, Dr. Paul McHugh wrote in The Wall Street Journal about this research, “Most shockingly, their suicide mortality rose almost 20-fold above the comparable non-transgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery. The high suicide rate certainly challenges the surgery prescription” ( McHugh 2014 ).

In the same article, Dr. McHugh has also described his study of people with gender confusion over the past forty years, twenty-six of which he spent as the psychiatrist in chief of Johns Hopkins Hospital. He wrote, “In fact, gender dysphoria—the official psychiatric term for feeling oneself to be of the opposite sex—belongs in the family of similarly disordered assumptions about the body, such as anorexia nervosa and body dysmorphic disorder. Its treatment should not be directed at the body as with surgery and hormones any more than one treats obesity-fearing anorexic patients with liposuction.” He went on, “The treatment should strive to correct the false, problematic nature of the assumption and to resolve the psychological conflicts provoking it. With youngsters, this is best done in family therapy” ( McHugh 2014 ).

Important medical and psychological issues need to be considered before the educational, medical, political, and judicial systems rush headlong into a process of affirming in youth and in their parents a fixed, false belief that a person can be a sex that is not consistent with their biological and genetic identity and that such individuals have the right to transsexual surgery. Fixed, false beliefs are identified in the mental-health field as manifestations of a serious thinking disorder, specifically a delusion. Health professionals should not be supporting this delusional belief in these youth and their parents.

An understanding of what motivates youth to identify with the opposite sex is essential as well as the reasons why parents would encourage or support transsexual attraction. Dale O'Leary, the author of the important book The Gender Agenda , has co-authored an important 2015 research paper, “Understanding and Responding to the Transgender Movement” ( O'Leary and Sprigg 2015 ). Parents, youth and adults with TSA and health professionals would benefit from reviewing this important research paper.

GID/Gender Dysphoria: The Most Common Precursor to Transsexual Conflicts

Many youths who identify as persons of the opposite sex meet the earlier DSM criteria for GID. GID is a childhood psychiatric disorder (DSM IV TR) in which there is a strong and persistent cross-gender identification with at least four of the following preferences:

• •  repeated stated desire to be of the opposite sex,
• •  in boys, a preference for cross-dressing or simulating female attire and, in girls, wearing stereotypical masculine clothing and a rejection of feminine clothing such as skirts,
• •  a strong and persistent preference for cross-sex role in play,
• •  a strong preference for playmates of the opposite sex, and
• •  an intense desire to participate in games and pastimes typical of the opposite sex.

The DSM 5 has replaced the diagnosis GID with a new diagnosis, gender dysphoria. It also describes the symptoms that arise from the failure to identify with one's biological sex.

Children who seek SRS should be evaluated for psychological conflicts but regularly are not. A Dutch researcher and clinician, who specializes in treating such youth, Dr. Peggy T. Cohen-Kettenis has written in this regard:

The percentage of children coming to our clinic with GID as adolescents wanting sex reassignment is much higher than the reported percentages in the literature … We believe (psychological) treatment should be available for all children with GID, regardless of their eventual sexual orientation. ( Cohen-Kettenis 2001 )

A Study of Youth from a Gender Identity Center

A 2013 study from a gender identity service in Toronto, that consisted of a sample of 577 children (ages 3–12) and 253 adolescents (ages 13–20), reported a number of findings and comments. These included:

• •  A sharp increase in adolescent referrals starting with the 2004–2007 cohort and this increased even more so in the last cohort, 2008–2011.
• •  For the first six cohorts (1976–1999), the percentage of boys always exceeded 75 percent, with the sex ratio ranging from a low of 4.61:1 (1988–1991) to a high of 12:1 of boys to girls (1992–1995), but for the last three cohorts (2000–2011) hovered around 75 percent, with the sex ratio ranging from 2.77:1 (2000–2003) to 3.41:1 (2008–2011) of boys to girls.
• •  The adolescent sex ratios were closer to parity. Of note, there were two cohorts (1988–1991 and 2008–2011) in which the number of girls exceeded the number of boys.
• •  The adolescent cases increased even more from the 2004 to 2007 cohort; and in the 2008 to 2011 cohort, the number of adolescent cases exceeded the number of child cases for the first time since the inception of their clinic in the mid-1970s.
• •  For the adolescents, data on sexual orientation were available for 248 patients. The percentage of girls classified as homosexual was greater than the percentage of boys classified as homosexual (76.0% vs. 56.7%).

For the children, 66.4 percent were in two-parent families at the time of assessment compared with 45.8 percent of the adolescents ( Wood et al. 2013 ). Another parameter that struck them as clinically important was that a number of youth commented that, in some ways, it was easier to be transsexual than to be gay or lesbian.

Along similar lines, they have also wondered whether, in some ways, identifying as transsexual has come to occupy a more valued social status than identifying as gay or lesbian in some youth subcultures. Perhaps this social force explains, at least partially, the particularly dramatic increase in female adolescent cases in the 2008–2011 cohort.

Another factor that impressed them in accounting for the increase in adolescent referrals pertained to youth with gender identify disorder who also had an autism spectrum disorder which has been reported by others ( de Varies et al. 2010 ). A center in the Netherlands reported the co-occurrence of GID and autism spectrum disorders (ASD) in a study of children and adolescents (115 boys and 89 girls, mean age 10.8). The incidence of ASD was 7.8 percent. The authors recommended acquiring a greater awareness “of co-occurring ASD and GID and the challenges it generates in clinical management.”

Family Conflicts in Youth with Gender Identity Confusion/Gender Dysphoria

Drs. Zucker and Bradley in Toronto have been recognized as leaders in the study of GID. They have identified a number of conflicts in the families of children with GID that included:

A composite measure of maternal psychopathology correlated quite strongly with Child Behavior Checklist indices of behavior problems in boys with GID.

The rate of maternal psychopathology is high by any standard and includes depression and bipolar disorder.

The boy, who is highly sensitive to maternal signals, perceives the mother's feelings of depression and anger. Because of his own insecurity, he is all the more threatened by his mother's anger or hostility, which he perceives as directed at him. His worry about the loss of his mother intensifies his conflict over his own anger, resulting in high levels of arousal or anxiety. The father's own difficulty with affect regulation and inner sense of inadequacy usually produces withdrawal rather than approach.

The parents have difficulty resolving the conflicts they experience in their own marital relations, and fail to provide support to each other. This produces an intensified sense of conflict and hostility.

In this situation, the boy becomes increasingly unsure about his own self-value because of the mother's withdrawal or anger and the father's failure to intercede. This anxiety and insecurity intensify, as does his anger.

These men (fathers) are often easily threatened and feel inadequate themselves. These qualities appear to make it very difficult for them to connect with sons who display non-masculine behavior.” Withdrawing from their feminine sons, “they often deal with their conflicts by overwork or distancing themselves from their families. The fathers’ difficulty expressing feelings, and their inner sense of inadequacy are the roots of this emotional withdrawal.

Fathers demonstrate depression and substance abuse disorder.

Parental psychopathology among the parents of children with GID deserves thoughtful consideration. ( Zucker et al. 2003 )

Also, Dr. Bradley has described additional maternal conflicts in these youth,

boys with GID appear to believe that they will be more valued by their families or that they will get in less trouble as girls than as boys. These beliefs are related to parents’ experiences within their families of origin especially tendencies on the part of mothers to be frightened by male aggression or to be in need of nurturing, which they perceive as a female characteristic. ( Bradley 2003 , 201–202)

Zucker et al. (2012 ) also found that GID youth had high rates of general behavior problems and poor peer relations.

It should be noted that these observations are not derived from controlled studies. As such, there is no comparison to the prevalence of such conflicts among control groups. Thus the specificity of these conflicts (or their prevalence in children with gender dysphoria) is not clear. There is no conclusive evidence of the role of such conflicts in the development of gender dysphoria or whether treatment aimed at correcting these leads to improvement. However, the comments of Zucker and Bradley do seem relevant to understanding the development of GID.

Additional conflicts that we have seen in engaging in the family therapy recommended by Dr. Paul McHugh include:

In females’ relationships with their fathers, observed conflicts may include:

• 1.  Excessive fear of the father's anger or his controlling behaviors, leading to a fear of being hurt due to being a woman, coupled with a belief that being a male would help them feel stronger and safer;
• 2.  Severe mistrust of the father because of his insensitive and angry treatment of the mother, because of his harming the family by abandonment or because of his emotional, personality, or behavioral conflicts;
• 3.  The father's failure to affirm his daughter's feminine goodness and gifts, to critique and protect her from gender theory errors, and to communicate that fulfillment and happiness can be found in being a psychologically healthy female.

In males’ relationships with their mothers, observed conflicts may include:

• 1.  The mother's mistrust of and anxiety with males as a result of growing up with a harsh, angry, distant, or addicted father (the child's grandfather);
• 2.  Her desire that her son had been a daughter, leading to initiating or supporting cross dressing and cross-sexual identification;
• 3.  A boy's fears that he does not please his mother as a male, together with his unconscious belief that he might receive more love and acceptance from his mother if he identified with femininity;
• 4.  A mother's failure to support and encourage her son to have same-sex friendships;
• 5.  A failure to critique and protect him from gender theory errors;
• 6.  A failure to communicate that fulfillment and happiness can be found in being a psychologically healthy male.

In males’ relationships with their fathers, observed conflicts may include:

• 1.  Failure to develop a secure father–son relationship because of a father's emotionally distant behaviors or severe male insecurity;
• 2.  A father's excessive anger or rejecting behaviors that undermine a son's ability to model after his father or that create a negative view of masculinity;
• 3.  A father's failure to support a son's strong creative and artistic gifts;
• 4.  A failure to protect the son from abusive behaviors by siblings or by same-sex peers that contribute to a son's failure to identify with the goodness of masculinity;
• 5.  A failure to support same-sex friendships in childhood and adolescence;
• 6.  A failure to critique and protect youth from gender theory errors;
• 7.  A failure to communicate that fulfillment and happiness can be found in being a psychologically healthy male.

In females’ relationships with their mothers, observed conflicts may include:

• 1.  An emotionally distant, angry, selfish, depressed, or critical mother who failed to bond closely with her daughter for any number of reasons, including unresolved anger with the maternal grandmother that was misdirected at the daughter;
• 2.  The failure to affirm the daughter's goodness and female gifts;
• 3.  A failure to support and encourage same sex friendships;
• 4.  A failure to critique and protect her daughter from gender theory errors;
• 5.  A failure to communicate that fulfillment and happiness can be found in being a psychologically healthy female.

Other factors and conflicts observed in males may include:

• 1.  A keen appreciation and love for beauty that is often associated more with femininity than masculinity and a desire to be what one loves;
• 2.  A poor body image and the belief that one would be more attractive if he were of the opposite sex;
• 3.  Severe childhood rejection by same-sex peers, creating a sense of not fitting in with them, which results in intense fears of rejection and an unconscious belief that one would feel safer if he were of the opposite sex;
• 4.  Repeated failures in relationships with women, associated with a severe loss of self-esteem;
• 5.  A sense of pleasure in rejecting the values and moral code of his parents;
• 6.  The belief that his sex is not a gift, but a constraint that must be overcome;
• 7.  Pressure from a significant other to cross dress, take hormones, and move toward SRS;
• 8.  Severe narcissism and acceptance of gender theory with a delusional belief that he can create himself as he wants.

Other factors and conflicts observed in females may include:

• 1.  The absence of close female friendships and a sense of not fitting in, along with a belief that she would be less lonely and happier if she were a male;
• 2.  In strong, young females, a love for what is perceived as male strength and preferential treatment for males, together with the desire to become what she loves;
• 3.  Poor body image and a belief that she would be more attractive if she were of the opposite sex;
• 4.  In very athletic and strong young females an intense bonding and identification with young males through athletic activities;
• 5.  A sense of failure as a female and a delusional belief that she would feel more confident and happy being a member of the opposite sex;
• 6.  Repeated failures in relationships with males with severe loss of self-esteem;
• 8.  A sense of pleasure in rejecting the values and moral code of her parents;
• 9.  The view that her sex is not a gift but as a constraint that must be overcome;
• 10.  Acceptance of gender theory, along with a delusional belief that she can create herself as she wants.

The exposure of youth to gender theory in college can result in their embrace of postmodern philosophies focused on freedom as an end in and of itself. Such ideas come from various sources, including the writings of Friedrich Nietzsche and Jean-Paul Sartre. If freedom (some would call it license) is the greatest good in the world, then why should anyone be constrained by biology? One's sex as male and female is seen not as a gift but as a constraint that must be overcome. So if technology can alter one's body, then so be it.

PC Medicine

Some medical centers fail to or refuse to diagnose the psychological difficulties youth have in accepting and appreciating their biological sex. They neglect to provide proper counseling about treatment and the risks of sexual-reassignment surgery. Instead, they support the beliefs of the youths and their parents and initiate hormone treatments in preparation for eventual body-mutilating surgery.

A pediatric specialist at Boston has a program for boys who feel like girls and girls who want to be boys. He offers his patients—some as young as seven years old—counseling about the “naturalness” of their feelings and hormones to delay the onset of puberty. These drugs stop the natural process of sexual development that would make it more surgically difficult to have a sex alteration later in life.

This physician alleges that those whom he labels as transsexual children are deeply troubled by a lack of understanding of their feelings and have a high level of suicide attempts. While this physician is accurate in his interpretation of the literature—that children with GID and transsexual ideation are deeply troubled—his claims of a high level of suicide attempts in children with GID is not substantially supported by the medical literature. In fact, the literature demonstrates a shocking increase in suicide and in psychiatric illness after sexual reassignment surgery ( Dhejne et al. 2011 ).

In his 2014 Wall Street Journal article, Dr. McHugh wrote that “misguided doctors at medical centers including Boston's Children's Hospital have begun trying to treat” transgenderism in youths “even though the drugs stunt the children's growth and risk causing sterility.” He recommends “a better way to help these children: with devoted parenting” ( McHugh 2014 ).

The Treatment of Youth with Transsexual Confusion

According to Drs. Zucker and Bradley:

The fantasy solution provides relief but at a cost. They are unhappy children who are using their cross-gender behaviors to deal with their distress.

Treatment goal is to develop same-sex skills and friendships.

In general, we concur with those who believe that the earlier treatment begins, the better … It has been our experience that a sizable number of children and their families can achieve a great deal of change.

In these cases, the gender identity disorder resolves fully, and nothing in the children's behavior or fantasy suggest that gender identity issues remain problematic … All things considered, however, we take the position that in such cases clinicians should be optimistic, not nihilistic, about the possibility of helping the children to become more secure in their gender identity. ( Zucker and Bradley 1995 , 281–282)

Zucker and Bradley have been providing sensitive treatment to children with the precursor of transsexual conflicts. They have written that the goal of treatment is to develop skills associated with children of their own biological sex and friendships with such children. We have found a similar treatment approach to be beneficial in treating such children ( Fitzgibbons 2015 ). While data from controlled clinical studies are not available to measure the effectiveness of these therapies, it seems reasonable to follow the recommendations of those with extensive clinical experience until such time as controlled trials are performed.

Also, Dr. McHugh has written that transsexual attractions are often fluid and can change. “When children who reported transsexual feelings were tracked without medical or surgical treatment at both Vanderbilt University and London's Portman Clinic, 70 to 80 percent of them spontaneously lost those feelings” ( McHugh 2014 ). Dr. McHugh has described also his research experiences at Johns Hopkins:

As for the adults who came to us claiming to have discovered their true sexual identity and to have heard about sex-change operations, we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them for surgery and for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it.

One might expect that those who claim that sexual identity has no biological or physical basis would bring forth more evidence to persuade others. But as I've learned, there is a prejudice in favor of the idea that nature is totally malleable.

A practice that appears to give people what they want turns out to be difficult to combat with ordinary professional experience and wisdom. Even controlled trials or careful follow-up studies to ensure that the practice itself is not damaging are often resisted and the results rejected. ( McHugh 2004 )

Sexual Reassignment Surgery

SRS violates basic medical and ethical principles and is therefore not ethically or medically appropriate.

• 1 SRS mutilates a healthy, non-diseased body. To perform surgery on a healthy body involves unnecessary risks; therefore, SRS violates the principle primum non nocere , “first, do no harm.”
• 2 Candidates for SRS may believe that they are trapped in the bodies of the wrong sex and therefore desire or, more accurately, demand SRS; however, this belief is generated by a disordered perception of self. Such a fixed, irrational belief is appropriately described as a delusion.
• 3 SRS, therefore, is a “category mistake”—it offers a surgical solution for psychological problems, such as a failure to accept the goodness of one's masculinity or femininity, lack of secure attachment relationships in childhood with same-sex peers or a parent, self-rejection, untreated GID, addiction to masturbation and fantasy, poor body image, excessive anger and rebelliousness, and severe psychopathology in a parent.
• 4 SRS does not accomplish what it claims to accomplish. It does not change a person's sex; therefore, it provides no true benefit.
• 5 SRS is a “permanent,” effectively unchangeable, and often unsatisfying surgical attempt to change what may be only a temporary (i.e., psychotherapeutically changeable) psychological/psychiatric condition. ( Fitzgibbons, Sutton, and O'Leary 2009 )

Regrets over SRS

Dr. Renee Richards, a former professional tennis player, has written that her transition failed to meet even her own expectations. She wrote,

I wish that there could have been an alternative way, but there wasn't in 1975. If there was a drug that I could have taken that would have reduced the pressure, I would have been better off staying the way I was—a totally intact person. I know deep down that I'm a second-class woman. I get a lot of inquiries from would-be transsexuals, but I don't want anyone to hold me out as an example to follow. Today there are better choices, including medication, for dealing with the compulsion to cross-dress and the depression that comes from gender confusion. As far as being fulfilled as a woman, I'm not as fulfilled as I dreamed of being. I get a lot of letters from people who are considering having this operation … and I discourage them all. ( Richards 1999 )

Walt Heyer, who went through SRS, also exposes the origins of the practice and its often tragic results in his article ( Heyer 2015 ).

Youth, their parents, and adults who are considering SRS should be informed by their doctors and psychologists about the serious regrets many people have who underwent SRS. This information should also be communicated in schools where SRS is being taught as a healthy step to seeking greater happiness and fulfillment in life.

Parental Responses to Youth with Transsexual Attractions

As the protectors of their children, the first step parents can take is to understand possible reasons why their child is identifying with the opposite sex and has difficulty in embracing the goodness of his masculinity or her femininity. Then parents should learn about the serious health risks associated with SRS. Next, it is essential to do what most health professionals, educators, and the media fail to do, warn their children of the serious psychiatric dangers associated with SRS, especially the risk of suicide.

Many parents report the benefits of limiting time on the Internet for their children with this conflict. They believe that communication with those who are supporting and encouraging SRS reinforces the false belief that their thinking can determine their sex, that they have no emotional conflicts, and that SRS is a path they should pursue.

The leading experts in GID, Zucker and Bradley, have written, “parental ambivalence is, in most cases part of the problem.” Parents, particularly mothers, who might rationalize that it is “cute” to have a boy wear female clothing, often ignore or excuse obvious appearances of effeminacy in males. These psychologists encourage early intervention to prevent the suffering of isolation, unhappiness, and low self-esteem in children who fail to appreciate their goodness as boys or girls.

Children are born with a drive to seek love and acceptance from each parent, as well as siblings and peers. If this need is met, children develop a positive identification with their masculinity or femininity. When this developmental task is successfully completed, the child is free to choose gender-atypical activities. Boys and girls with gender-identity problems are not freely experimenting with gender-atypical activities. They are constrained by deep insecurities and fears and are reacting against the reality of their own sexual identity, often as a result of failing to experience secure attachment relationships with the parents, siblings, or same-sex peers.

Mistakes parents make with children who have transsexual attractions (TSA) may include:

• •  failing to identify a child's weakness in embracing the goodness of his masculinity or her femininity;
• •  allowing a child unsupervised time on the Internet, especially in the evenings, during which the delusional belief that one can change one's sex can be communicated and affirmed;
• •  failing to help understand the causes of their conflicts;
• •  failing to warn about the severe dangers of SRS;
• •  enabling the delusional thinking that one can change one's sex;
• •  depending too much on acceptance by a child;
• •  allowing a child to see a health professional who fails to provide adequate information and who fails to explore possible psychological origins of the failure to embrace the goodness of masculinity or femininity;
• •  failing to get a professional opinion about the origins of transsexual attractions and the serious risks associated with sexual reassignment surgery;
• •  supporting the controlling behavior of the child who insists upon being called by a name of the opposite sex at home and at school;
• •  enabling communication with peers and others who encourage SRS.

Children can also learn to correct their cognitive distortions in regard to their natural goodness and beauty as a male or female. The responses could include thinking:

“I can grow to appreciate the goodness of my body and masculinity and femininity.”

“I can be thankful for my special masculinity or femininity.”

“I can grow to feel more comfortable and confident in being who I am.”

While there are no controlled clinical data to support specific interventions in treating children with transsexual conflicts, the following recommendations could be helpful if incorporated into a family therapy treatment program. For boys with transsexual conflicts:

• •  increasing quality time for bonding with the father;
• •  increasing affirmation of the son's masculine gifts by the father;
• •  bonding with the son in his artistic or creative activities;
• •  participating in and support for the son's creative efforts by the father;
• •  encouraging same-sex friendships and diminishing time with opposite-sex friends;
• •  slowly diminishing play with opposite-sex toys;
• •  encouraging the boy to be thankful for his special male gifts;
• •  working at forgiving boys who may have hurt him;
• •  communicating with other parents whose children have been treated successfully for GID and who have come to appreciate and to embrace the goodness of their masculinity and femininity;
• •  addressing the emotional conflicts in a mother who wants her son to be a girl;
• •  in those with faith, encouraging thankfulness for one's special, God-given masculine gifts.

For girls with transsexual conflicts:

• •  encouraging the daughter to appreciate the goodness and beauty of her femininity, including her body;
• •  encouraging same-sex friendships and activities;
• •  increasing the mother–child quality time;
• •  praising their daughter's special goodness and gifts;
• •  working with the daughter to forgive peers who have hurt her;
• •  encouraging pursuit of a balance in athletic activities;
• •  addressing conflicts in a parent who may want her to be a boy;
• •  in those with faith, encouraging thankfulness for one's special, God-given femininity.

Transsexual Indoctrination in Schools

Some school districts have been attempting to incorporate transsexual education into the required health programs in junior and senior high schools. In the Fairfax County, Virginia, School District, parents’ groups strongly objected to this attempt; and the program was left in the family life section which is not required for students. In an important article, “Gender Free Children: The newest fad in public education,” the British Columbia Teachers Federation handbook on gender education was cited. It stated that “gender is a product of the mind … Being transgender or gender non-conforming is normal and healthy.”

Author Lee Duigon wrote,

Coming soon, to a public school near you: the teaching that “gender is a spectrum,’ and ‘gender identity” a state of mind, a social construct—and it's all part of a top-down campaign to convince your children that they can be “whoever they want to be.” Boys can be girls and girls can be boys. ( Duigon 2011 )

The author noted that the Redwood Heights Elementary School in Oakland, California, has already installed a “gender coach” in the classroom to teach very young children that “you can be a boy or a girl, or both.” The “coach” was provided by an organization called Gender Spectrum (http:// www.genderspectrum.org ) which presumably would not exist if it did not perceive a demand for its services.

In addition, school principals are placing children at risk and are creating confusion in the minds of many children by giving in to the requests of parents to allow young children to change their names to those of the opposite sex, cross dress, and be accepted as being of the sex opposite of their biological sex. These school administrators either do not know or ignore medical and psychological science and research on transsexual issues and SRS. They are participating in a false belief that the children are not of their biological sex. Such a fixed, false belief is identified in the mental health field as a delusion.

Faith and Transsexual Issues

While he has not specifically addressed the issue of transsexualism, Pope Francis has repeatedly criticized gender theory indoctrination of youth. On January 19, 2015, in an in-flight interview returning from Manila, he described the forcing of gender ideology onto students in schools as a form of “ideological colonization” comparable to Hitler youth indoctrination ( Westen 2015 ). Pope Francis commented on April 15, 2015, at his weekly general audience: “if so-called gender theory is not an expression of frustration and resignation, that aims to cancel out sexual difference as it is no longer able to face it. Yes, we run the risk of taking a step backwards. Indeed, the removal of difference is the problem, not the solution” ( White 2015 ). On June 8, 2015, he stated that so-called gender ideology is challenging the complementarity between a man and a woman under the guise of seeking a more just society. He related, “Let me draw your attention to the value and beauty of marriage. The differences between men and women are not of the order of opposition or subordination, but rather communion and generation, always as the image and semblance of God” ( Montagna 2015 ).

Similarly, Pope Benedict XVI strongly criticized gender theory in his Christmas address to the Roman Curia, December 22, 2008. He stated,

She [the Church] has a responsibility towards creation, and must also publicly assert this responsibility. In so doing, she must not only defend earth, water and air as gifts of creation belonging to all. She must also protect man from self-destruction … .

What is often expressed and understood by the term “gender” ultimately ends up being man's attempt at self-emancipation from creation and the Creator. Man wants to be his own master, and alone—always and exclusively—to determine everything that concerns him. Yet in this way he lives in opposition to the truth, in opposition to the Creator Spirit.

Rain forests deserve indeed to be protected, but no less so does man, as a creature having an innate “message” which does not contradict our freedom, but is instead its very premise. ( Benedict XVI 2008 )

Youth have the right to be provided, by physicians, mental health professionals, school nurses, and the media, with accurate information about gender confusion, the serious medical and psychiatric associated with SRS, and the excellent prognosis associated with an alternative proven treatment described in the medical literature.

Parents, family members, educators, politicians, and clergy have a moral responsibility to be familiar with medical science and to provide prudent counsel to youth that will protect and not harm them.

Biographical Note

Richard Fitzgibbons, M.D., has practiced psychiatry for forty years. He trained at the Hospital of the University of Pennsylvania and the Philadelphia Child Guidance Center. He has worked extensively with marital and family conflicts.

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