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What’s Life Like After Undergoing Gender Confirmation Surgery?

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Answer by Tamara Wiens , in transition since 2012:

I’ve answered some of this before in here , so I will focus on the differences physically, psychologically, and practically between the different sets of genitalia, from a fully transitioned perspective (i.e., I won’t be answering in the context of a man with a penis).

Physically, it’s quite different, as you would expect. The obvious things include:

Urination—although I was sitting to pee long before, doing that with a penis requires spread legs to let the urine flow, and holding things down to prevent reflexive jerking and splashing. You can also pull the toilet paper as you are peeing, hard to do when you have one hand holding things in place.

Washing—cleaning a penis and scrotum (I was circumcised) is very simple. You can get all of it without effort. With vulva and a vagina, it’s much more complicated, as the water doesn’t flow there naturally in the shower, and you need to either use a movable shower head that can spray up or cup water to splash it into the labia. Even then, cleaning the folds can be done, but you can’t get inside, even in the tub, without douching (which isn’t advised due to creating imbalances of the internal flora).

Dressing—there are a number of things here. First, I don’t need to tuck anymore. I was long enough that it required quite a bit of effort, and left my penis between my butt cheeks, which resulted in chafing on both parts in a surprisingly large number of circumstances. I tried gaffes, but they were terribly painful, even more than the chafing from tucking, so I stayed away from them. I also had to tuck my testicles—all of this was an intricate package that could be disturbed by wide-spread legs, or the “gallant reflex” (although hormones mostly took care of that). It also precluded some outfits (most swimsuits, any outfit that is sheer or tightfitting enough to require no underwear) or made them painful (tight jeans, pants that ride high in the crotch). None of those things is an issue any longer—I can wear any swimsuit (well, any one that flatters the rest of my shape!), pants, etc, and no motion is forbidden to me at the cost of rearrangement.

Sensation—I have heard that the vagina of cis women has no sensation, other than the first inch or so. It hasn’t come up in conversation since my surgery, so I don’t know if this is truly the case, but I can tell you that I do have sensation in my vagina. I have an occasional “itch” on my “penis shaft,” just below the “head” … or at least that’s how my brain interprets it. However, that spot is about 6 inches inside me now—thankfully, none of the itches has lasted long—and I can no longer just scratch at it!

Psychologically, it’s interesting—before the surgery, there was this sense of … not distaste so much as wrongness. I didn’t want to talk about it, or look at it, or do anything with it, other than what I had to. There was also quite a bit of fear that I associated with it, mostly associated with getting found out, in a public washroom or as part of a sexual assault. Fortunately, I haven’t yet been sexually assaulted, but I had a fear that, if a rapist attacked me and discovered that I wasn’t what he expected, an assault might quickly become a murder. Having that genetic defect corrected has been incredibly freeing—I have no sense of loss, just a sense of rightness. Frankly, most of the time, I have no sense of it at all—it just IS, and it is what it’s supposed to be!

Practically, it’s a pain. Trust me, staying with the penis and scrotum would have been so much more practical from a “care and feeding” perspective, but given that this is what I needed to fully address my gender dysphoria, it’s a price I’m happy to pay.

First, there’s the cost—for me, it was financial, and pain, and time, and more time, and more time and pain. Even for those that can get provincial funding (in Canada, but not all provinces), there is the cost of another set of practitioners poking their noses into your business, that shouldn’t require anyone to be allowed to judge you, or gate-keep you, but they do. Even then, that doesn’t bypass the time and pain—first, of the surgery, then the healing and recovery, and more recovery, and often enough, more surgery with the additional pain and time to recover.

Second is the lifetime commitment. If you are interested in having vaginal sex, you will need to dilate at least once a week for the rest of your life, and for the first year, it’s much more (I figured it out once, it’s close to 700 times in the 12 months after surgery, which is the same as what you will do over the next 14 years, altogether).

Last is all the lube! I am one of Costco’s most faithful purchasers of that famous personal lubricants, for both dilating (think sex without arousal or pumping), and eventually also for sex. We simply don’t self-lubricate to the extent that cis women do, so we will need to use a tube whenever we want to get in there. In my case, I comfort myself with the knowledge that alot of other women in their late 40s are in situations that require the same kind of supports … but still not practical!

For any preop trans woman who would like more details, feel free to message me, and we can discuss the ins and outs (no, the pun was not intended) of the whole procedure. If anyone else would like more information, feel free—I’m happy to educate in this area of my personal expertise!

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

How Gender Reassignment Surgery Works (Infographic)

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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The 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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Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies

Sasha karan narayan.

1 Department of Surgery, Oregon Health and Science University, Portland, OR, USA;

Rayisa Hontscharuk

2 Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA;

Sara Danker

3 Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA;

Jess Guerriero

4 Transgender Health Program, Oregon Health & Science University, Portland, OR, USA;

Angela Carter

5 Primary Care, Equi Institute, Portland, OR, USA;

Gaines Blasdel

6 NYU Langone Health, New York, NY, USA;

Rachel Bluebond-Langner

Randi ettner.

7 University of Minnesota, Minneapolis, MN, USA;

8 Callen-Lorde Community Health Center, New York, NY, USA;

Loren Schechter

9 The University of Illinois at Chicago, Chicago, IL, USA;

10 Rush University Medical Center, Chicago, IL, USA;

11 The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA;

Jens Urs Berli

12 Division of Plastic & Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA

Associated Data

The article’s supplementary files as

A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons’ experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.

This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.

The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.

Conclusions

In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Introduction

Over the past several years, there has been sustained growth in institutional and social support for transgender and gender non-conforming (TGNC) care, including gender-affirming surgery (GAS) ( 1 ). The American Society of Plastic Surgeons (ASPS) estimates that in 2016, no less than 3,200 gender-affirming surgeries were performed by ASPS surgeons. This represents a 20% increase over 2015 ( 2 ) and may be partially attributable to an increase in third party coverage ( 3 , 4 ). A rare, but consequential, risk of GAS is post-operative regret that could lead to requests for surgical reversal. As the number of patients seeking surgery increases, the absolute number of patients who experience regret is also likely to increase. While access to gender-affirming health care has expanded, these gains are under continued threat by various independent organizations, religious, and political groups that are questioning the legitimacy of this aspect of healthcare despite an ever-growing body of scientific literature supporting the medical necessity of many surgical and non-surgical affirming interventions. It is therefore not surprising that studies on regret and surgical reversal are scarce compared to studies on satisfaction and patient-reported outcomes. The transgender community rightfully fears that studies on this topic can be miscited to undermine the right to access to healthcare.

The goal of this study is to assist patients, professionals, and policy makers regarding this important, albeit rare, occurrence. We do so by addressing the following:

• The current literature regarding the etiology of regret following gender-affirming surgery;
• The experience of surgeons regarding requests for surgical reversal.

Based on these results, the authors propose a classification system for both type and etiology of regret.

It is important to acknowledge that the authors identify along the gender spectrum and are experts in the field of transgender health (mental health, primary care, and surgery). We hope to facilitate discussion regarding this multifaceted and complex topic to provide a stepping-stone for future scientific discussion and guideline development. Our ultimate goal is to reduce the possibility of regret and provide clinical support to patients suffering from the sequelae of regret. We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-6204 ).

A 16-question survey (see Table S1 ) was developed and uploaded to the online survey platform SurveyMonkey (SurveyMonkey, Inc., San Mateo, CA, USA). This anonymous survey was e-mailed by the senior author to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. There were no incentives offered for completing this survey. One reminder e-mail was sent after the initial invitation.

Respondents were asked to describe their practices, including: country of practice, years in practice, a range estimate of the total number of TGNC patients surgically treated, and the number of TGNC patients seen in consultation who expressed regret and a desire to reverse or remove the gendered aspects of a previous gender-affirming surgery. We limited the questions to breast and genital procedures only. Facial surgery was excluded as there are no associated WPATH criteria, so there is less standardization of patient selection for surgery. Thus, we did not feel that those patients should be pooled with those who were subject to WPATH criteria in our calculation for prevalence of regret. We did not define the term “regret” in order to capture a wide range of responses. Respondents were asked about their patients’ gender-identification, the patient’s surgical transition history, and the patient’s reasons for requesting reversal surgery. If the respondents had experience with patients seeking reversal surgery, the number of such interventions were queried to include: the initial gender-affirming procedure and the patients’ reason(s) for requesting reversal procedures. The respondents were also asked about the number of reversal procedures they had performed, and what requirements, if any, they would/did have prior to performing such procedures. Finally, respondents were asked whether they believed that the WPATH Standards of Care 8 should address this topic.

Statistical analysis

Response rate was calculated from the total number of respondents as compared to the number of unique survey invitations sent. Responses to the survey were analyzed using descriptive statistics. When survey questions offered ranges, (i.e., estimating the number of patients surgically treated), the minimum and maximum values of each of the selected answers were independently summed to report a more comprehensible view of the data. Partially completed surveys were identified individually and accounted for in analysis. Any missing or incomplete data items from the survey were excluded from the results with the denominator adjusted accordingly.

Narrative literature review

A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret and satisfaction. Terms included (regret) and (transgender) and (surgery) or (satisfaction) and (transgender) and (surgery). These terms included their permutations according to the PubMed search methodology. Original research and review studies whose abstracts addressed the following topics were included for full-text review: gender-affirming surgery, sex reassignment, patient satisfaction, detransition, regret. A total of 163 abstracts were reviewed and a total of 21 articles were closely read for the relevant discussion of regret and satisfaction.

Ethical statement

This study was approved by the Oregon Health & Science Institutional Review Board #17450 and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Survey results

Of the 154 surgeons who received the survey between December 2017 and February 2018, 46 (30%) surgeons completed the survey. The survey, including its results, can be found in Table S1 . Thirty respondents (65%) were in practice for greater than 10 years, and most (67%) practice in the United States, followed by Europe (22%). The respondents treated between 18,125 and 27,325 TGNC or gender non-conforming (TGNC) patients. Most of the respondents (72%) surgically treated over 100 TGNC patients (see Figure 1 ). Of the 46 respondents, 61% of respondents encountered either at least one patient with regret regarding their surgical transition or a patient who sought a reversal procedure—irrespective of whether their initial surgery was performed by the respondent or another surgeon. Twelve respondents (26%) encountered one patient with regret, and the remaining 12 (26%) encountered two or more patients with regret. One respondent indicated that they encountered between 10 and 20 patients who regretted their surgical gender transition. No respondent encountered more than 20 such patients (see Figure 2 ). This amounted to a total of 62 patients with regret regarding surgical transition, or a 0.2% to 0.3% rate of regret. Of these 62 patients, 13 (21%) involved chest/breast surgery and 45 (73%) involved genital surgery (see Table 1 ).

Distribution of transgender surgery experiences among respondents.

Number of transgender patients encountered who expressed regret.

Totals do not add to 100 due to incomplete responses.

Of the 62 patients who sought surgical reversal procedures, at the time of their initial gender-affirming surgery, 19 patients identified as trans-men, 37 identified as trans women, and 6 identified as non-binary. The reasons for pursuing surgical reversal were provided for 46 patients (74%) and included: change in gender identity or misdiagnosis (26 patients, 42%), rejection or alienation from family or social support (9 patients, 15%), and difficulty in romantic relationships (7 patients, 11%). In some patients, surgical complications or social factors were cited as a reason for regret and request for reversal of genital surgery—no change in the patient’s gender identity was elucidated (see Table 2 , etiologies of regret). Of the 37 trans-women seeking reversal procedures, complaints at the time of secondary surgical consultation included: vaginal stenosis (7 patients), rectovaginal fistulae (2 patients), and chronic genital pain (3 patients). Of the 19 trans-men seeking reversal procedures, complaints at the time of secondary surgical consultation included: urethral fistulae (2 patients) and urethral stricture (1 patient). A total of 36 reversal procedures were reported, with supplemental qualitative descriptions provided for only 23 procedures. The distribution of the 23 reversal procedures is found in Table 1 .

Totals exceed 100 as respondents could select multiple options.

Most respondents (91%) indicated that new mental health evaluations would be required prior to performing surgical reversal procedures. Eighty-eight percent of respondents indicated that WPATH SOC 8 should include a chapter on reversal procedures (see Figure 3 ).

Respondent’s requirements to proceed with surgical reversal.

Literature review

Overall, the incidence of regret following gender-affirming surgery has been reported to be consistently very low ( 5 - 26 ). Wiepjes et al. ( 27 ) reported an overall incidence of surgical regret in the literature in transgender men as <1% and transgender women as <2%. Landen et al. comment that outcomes following gender-affirming surgery have improved due to preoperative patient assessment, more restrictive inclusion criteria, improved surgical techniques, and attention to postoperative psychosocial guidance ( 28 ). Although retrospective, the Wiepjes et al. study is the largest series to date and included 6,793 patients over 43 years. In this study, only 14 patients were classified as regretful, and only 10 of these patients pursued procedures consistent with intent to detransition. Perhaps most importantly, the Amsterdam team categorized regret into three main subtypes: “ social regret , true regret , and feeling non - binary ”.

Many of the reviewed studies aimed to identify various variables or risk factors that may identify patients that are at risk or that may predict future postoperative regret.

Earlier studies focused on patient characteristics and identified several variables that were associated with regret in their patient populations. These variables include psychological variables ( 11 , 22 , 23 ), such as previous history of depression ( 15 , 26 ), character pathology ( 26 ) or personality disorder ( 5 , 15 ), history of psychotic disorder ( 15 , 28 ), overactive temperament ( 26 ), negative self-image ( 26 ) or other psychopathology ( 15 , 19 , 26 ), as well as various social or familial factors that include history of family trauma ( 19 , 29 ), poor family support ( 5 , 11 , 15 , 28 ), belonging to a non-core group ( 28 ), previous marriage ( 15 , 19 ), and biological parenthood ( 15 , 19 ). Landen et al. identified poor family support as the most important variable predicting future postoperative regret in transgender men and women undergoing gender-affirming surgery in Sweden between 1972–1992 ( 28 ). Defined as subsequent application for reversal surgery, the authors found that 3.8% of their study population regretted their surgery. Other factors previously associated with regret include: sexual orientation ( 5 , 7 , 15 , 19 ), impaired postoperative sexual function [most notably in transgender women; ( 29 )], previous military service ( 29 ), a physically strenuous job ( 29 ), history of criminality ( 5 ), age at time of surgery and transition [>30 year increased risk; ( 5 , 6 , 11 , 15 , 19 , 29 )], asexual or hyposexual status preoperatively ( 15 , 29 ), too much or too little ambivalence regarding prospect of surgery ( 29 ), and/or an absence of gender nonconformity in childhood ( 15 ).

Studies examining transgender women have identified postoperative sexual function to be a significant factor contributing to possible surgical regret ( 15 , 29 ). A literature review by Hadj-Moussa et al. ( 11 ) (2018) identified poor sexual function as a factor that may contribute to postoperative regret in transgender women after vaginoplasty. Lindemalm et al. ( 29 ) (1986) previously reported a rate of 30% regret in their study examining 13 transgender women in Sweden after vaginoplasty. This rate of regret is the highest reported and appears to be an outlier. In their patient population, they found that only one third had a surgically-created vagina capable of sexual intercourse. This was consistent with patient-reported poor postoperative sexual function and highlights the importance of discussing sexual function following vaginoplasty. Similarly, Lawrence et al. ( 15 ) (2003) found that occasional regret was reported in 6% of transgender women after vaginoplasty, with 8 of the 15 regretful patients identifying disappointing physical and functional outcomes after their surgery. These findings are consistent with literature reviews that have found that regret is related to unsatisfactory surgical outcomes and poor postoperative function ( 19 , 30 ).

Transgender men have been found to manifest more favorable psychosocial outcomes following surgery and are less likely to report post-surgical regret ( 26 ). These findings highlight the importance of surgical results, and their influence on surgical regret. Despite this difference between transgender men and women, overall regret continues to remain low.

While the rate of surgical regret is low, many patients can suffer from many forms of “minor regret” after surgery. Although this could skew the outcomes data ( 30 ), this is considered temporary and can be overcome with counseling. As such, this should not be calculated in assessments of true regret ( 30 ). Alternatively, lasting regret is attributed to gender dysphoria and is explicitly expressed through patient postoperative behaviors ( 30 ). Factors that have been found to contribute to “minor regret” after gender-affirming surgery include postsurgical factors such as pain during and after surgery, surgical complications, poor surgical results, loss of partners, loss of job, conflict with family, and disappointments that various expectations linked to surgery were not fulfilled ( 19 ). Previous reviews further underline the importance of following the contemporaneous WPATH Standards of Care. This is especially important regarding patient education pertaining to surgical expectations and outcomes ( 11 , 26 ). Patient education programs are thought to identify those individuals who would most benefit from surgery ( 20 ). Other issues reported to decrease postoperative regret include appropriate preoperative diagnosis ( 19 , 20 , 26 ), consistent administration of hormone therapy ( 15 ), adequate psychotherapy ( 15 ), and the extent to which a patient undergoes a preoperative “real-life test” living in their desired gender role ( 15 , 19 , 20 , 26 ).

As compared to the volume of literature regarding postoperative satisfaction following gender-affirming surgery, the literature on regret is still relatively small. However, the literature (and anecdotal surgeon reports) consistently shows low rates of regret. We juxtaposed these findings to the surgeons’ experience with patients seeking reversal surgery or verbalizing regret. We found a rate of regret between 0.2–0.3%. This is consistent with the most recent data from Wiepjes et al. who reported rates of regret of 0.3% for trans-masculine and 0.6% for trans-feminine patients ( 27 ). The question of prevalence seems relatively well-answered by the current literature.

Perhaps the most striking finding is the heterogeneity of etiologies and risk factors associated with regret. Within this context, establishing consistent definitions for both regret and its underlying etiology is essential. Furthermore, as our understanding of gender identity evolves, our definitions and understanding become more precise. We highlight the Wiepjes et al. classification as an example of how narrower definitions may preclude an understanding of evolving gender theory. This predominantly single-institution study included 6,793 individuals, and the authors classified regret into three subtypes: social regret, true regret, and feeling non-binary. They categorized patients as either trans-female or trans-male. Conversely, in the 2015 US Transgender Survey, 35% of the nearly 28,000 respondents reported a non-binary identification ( 31 ). The classification by Wiepjes et al. is important in that it recognizes that individuals may not regret “transitioning”, but rather regret specific aspects of their medical treatment. More specifically, if these individuals request a reversal procedure, they are not necessarily requesting a “reversal” of their gender identity. However, the Wiepjes et al. study does not elaborate on this topic.

Case example: a trans-masculine, non-binary individual after testosterone therapy and chest masculinization regrets having secondary sex characteristics from hormonal therapy but is highly satisfied following chest masculinization. This should be considered true gender-related regret as the individual desires, at least in part, to return to the phenotype of the sex assigned at birth (e.g., hair removal). However, the etiology regarding this type of regret can be varied. For example, the etiology may include: insufficient exploration of the individual’s gender identity [by the individual and/or mental health professional (misdiagnosis)], lack of knowledge of professionals regarding surgical options for non-binary individuals, insurance carrier mandate to undergo hormonal therapy prior to chest masculinization (healthcare stigma), etc.

Based on the reviewed literature and our consensus expert opinion, we propose the following classification of regret, examples of etiology pertaining to regret ( Table 3 ), and an overview of associated terminology regarding regret ( Table 4 ).

Regret is a general term that describes an emotional state wherein a previous decision now feels incorrect. This can be temporary (fleeting ambivalence) or permanent. Permanent regret can be divided into three forms: true gender-related regret, social regret, and medical regret.

True gender-related regret involves a person having undergone a transition in gender whether by social, medical, or surgical means, indicating a formal change in gender identity, who then desires to return to their assigned sex at birth or a different gender identity. True gender-related regret differs from other types of regret in that it implies a misdiagnosis or misinterpretation of gender incongruence at the time of transition. Based on the case example, true gender-related regret need not be related to all medical treatments, but instead may be focused on specific treatments for which the individual seeks reversal. True gender-related regret constituted 42% of the requests for surgical reversal in our study. Etiology may include: misdiagnosis, insufficient exploration of gender identity, or barriers to access for options to transition to non-binary gender expression.

Social regret refers to one’s desire to return to their sex assigned at birth to alleviate the repercussions of transitioning on their social life. The etiologies can vary widely and include feeling unsafe in public, losing partnership, feeling unable to partake in one’s community, and encountering professional barriers. An additional reason identified in this study included religious conflict, mentioned in 9% of individuals. Social regret was cited in 37.1% of the requests for surgical reversal.

Medical regret includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof. This area is particularly important for the medical community as it is preventable and may increase as access to care expands. Medical regret can be further subdivided into regret secondary to medical complications, long-term functional outcomes (i.e., sexual), and preoperative decision-making.

Medical regret due to inadequate preoperative decision-making is directly related to a medical intervention, but it is not due to a change in gender identity, medical complication, functional outcome, or social stigma. Examples include choosing a simple-release metoidioplasty rather than a phalloplasty or regretting gonadal sterilization later in life ( 32 ). In these situations, individuals may not have appreciated the long-term implications at the time they underwent the procedure, may have received incomplete or inaccurate counseling, may have had a change in life goals, or may have not had access to technologies that are currently available. This form of regret may be mitigated by employing a multidisciplinary approach which includes discussions beyond surgical risks (i.e., fertility preservation, sexuality, etc.) ( 33 , 34 ). Medical regret was cited in 8% of requests for reversal, however 24% of patients were separately noted to have experienced post-operative complications.

Associated definitions

Gender fluidity is an inclusive term describing gender along a spectrum rather than a binary construct. When applied to identity, gender fluidity, sometimes called “genderqueer” ( 35 , 36 ) describes an individual who remains flexible regarding their identity and may identify differently at different times in their lives. Surgeons should work collaboratively with their mental health colleagues to help the patient understand the impact of surgery and how surgery may influence/affect future life goals. Non-identified gender fluidity can be one etiology for true gender-related regret.

Continued transition medically recognizes the concept of gender fluidity and the gender spectrum. This patient seeks additional medical treatment following their initial gender-affirming procedure(s) and may express an evolving gender identity or request further surgical consolidation of their identity. The patient need not express regret over their initial transition. An example is a patient assigned male-at-birth who takes feminizing hormones and undergoes breast augmentation. Subsequently, the patient returns to the surgeon indicating they identify as non-binary and requests implant removal. With decreased stigmatization of non-binary gender identity and ability to access non-binary affirming surgical options, this type of regret may be less common in the future.

Detransition refers to a change in gender role and/or the cessation of medical transition (e.g., hormonal treatment). This term has been used controversially and disparagingly with regards to surgical transition and fails to honor the spectrum of reasons why patients may undergo reversal surgery. However, some patients utilize this term to self-identify and to describe their experiences. This term should not be used to describe the process of surgical reversal.

Retransition is a phenomenon where a patient, following surgical reversal procedures, later feels that this reversal was wrong and seeks to re-affirm their previously expressed gender identity. A reason for retransition may include a change in societal structure that has provided a safer environment for transition. The need to distinguish continued transition from retransition results from a clash between increasing societal perception of a gender spectrum and the Western culture’s binary gender construct ( 35 ).

Fleeting ambivalence (considered short-term regret) over one’s transition is common, especially if the patient experiences initial surgical complications or loss of their support communities. The normal grief experienced as a result of trauma should not be pathologized, and the patient should be encouraged to trust in their long-standing gender identification. Some patients may desire a change in gender identify as a result of feeling unsafe due to severe social stigma. Knowing this, healthcare teams should counsel patients regarding the implications of transitioning within a given societal structure prior to surgery. This may include discussions regarding the effect of transitioning on relationships, careers, personal safety in public, sexuality, etc. These discussions are often facilitated by the patient’s mental health professional and/or primary care provider.

Special considerations

We recognize that regret and surgical reversal are complex, multifaceted phenomena without an easy treatment path. While both regret and requests for surgical reversal are rare, the need for guideline development is critical in providing high-quality care for this patient population, regardless of prevalence.

A concern expressed by both providers and patients is that discussions regarding regret and surgical reversal may be used to restrict access to affirming care. The authors believe that research including feelings of grief and regret will not only help individuals who experience severe forms of regret but will also help to refine surgical indications and procedures to minimize this already rare occurrence. Finally, and perhaps most importantly, failure to study regret and surgical reversal procedures will allow these topics to be left up to interpretation and may not reflect the actual experience of patients.

Limitations

The literature review was not performed systematically and as such is subject to selection bias. Our survey involved a survey of gender surgeons but did not include other medical or mental health professionals who may evaluate patients requesting surgical reversal. In addition, the study findings are limited by its design. Because survey studies are prone to recall bias, response bias, and selection bias, they are not well-suited for calculating the prevalence of a particular condition. For example, 89% of the respondents practice in the United States and Europe. This leaves significant areas of the world underrepresented and so does not represent the experiences or desires of all international surgeons. Furthermore, the survey was distributed in English only, as it was circulated to surgeons who attended conferences in the United States. Most notably, patients may have sought consultation from multiple surgeons resulting in an overestimation of the prevalence of regret. Conversely, patients seeking surgical reversal may not have had access to additional surgical care, causing an underestimate in the prevalence of regret. While our study findings are strengthened by external validation from other studies, the true prevalence of regret remains an estimate.

Regret after gender-affirming surgery was found to be rare, both in the literature as well as in our survey of surgeons’ experiences with this topic. Regret can be classified as true gender-related regret, social regret and medical regret from complications, function, pre-intervention decision making. Guidelines in transgender health should include both preventive strategies as well as treatment guidelines if regret occurs. Future studies and scientific discourse are encouraged on this important topic.

Supplementary

Acknowledgments.

The authors acknowledge the many surgeons who were surveyed in this work, and the community members who thusly contributed to the survey results.

This research was orally presented by Dr. Sasha Narayan at the Philadelphia Trans Wellness Conference (PTWC) August 2018 in Philadelphia, PA and at the World Professional Association for Transgender Health (WPATH) International Conference, November 2018 in Buenos Aires, Argentina. This research was orally presented by Dr. Sara Danker at Plastic Surgery, The Meeting (PSTM), October 2018 in Chicago, IL.

Funding : None.

Ethical Statement : The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Oregon Health & Science Institutional Review Board #17450. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Provenance and Peer Review : This article was commissioned by the Guest Editors (Drs. Oscar J. Manrique, John A Persing, and Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine . The article has undergone external peer review.

Reporting Checklist : The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-6204

Data Sharing Statement : Available at http://dx.doi.org/10.21037/atm-20-6204

Conflicts of Interest : All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6204 ). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. RBL reports that he serves on the standards of care committee of WPATH. No financial reward. Dr. AR reports that he serves as board member for World Professional Association for Transgender Health. This is an uncompensated position. Dr. LS reports other from Elsevier Publishing, other from Springer Publishing, outside the submitted work; and he serves on the board of WPATH (world professional association for transgender health), this is an unpaid position. Dr. JUB reports that he serves on the standards of care committee of the World professional association of transgender health. No financial reward associated with this. The authors have no other conflicts of interest to declare.

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“Everyone treated me like a saint”—In Iran, there’s only one way to survive as a transgender person

In Iran, homosexuality is a crime, punishable with death for men and lashings for women. But Iran is also the only Muslim country in the Persian Gulf region that gives trans citizens the right to have their gender identity recognized by the law. In fact, the Islamic Republic of Iran not only allows sex reassignment, but also subsidizes it.

Before the 1979 Islamic revolution in Iran there was no official government policy on transgender people. After the revolution, under the new religious government, transsexuals were placed in the same category as homosexuals,  condemned by Islamic leaders and considered illegal.

Things changed largely due to the efforts of Maryam Khatoon Molkara. Molkara was fired from her job, forcibly injected with male hormones and put in a psychiatric institution during the 1979 revolution. But thanks to her high-level contacts among Iran’s influential clerics, she was able to get released. Afterwards, she worked with several religious leaders to advocate for trans rights and eventually managed to wrangle a meeting with Ayatollah Khomeini, the “supreme leader” of Iran at the time. Molkara and her group were able to eventually convince Khamenei to pass a fatwa in 1986 declaring gender-confirmation surgery and hormone-replacement therapy religiously acceptable medical procedures.

Essentially, Molkara, the Iranian religious leaders she worked with, and the Iranian government had reframed the question of trans people. Trans people were no longer discussed as or thought of as deviants, but as having a medical illness (gender identity disorder) with a cure (sex reassignment surgery).

“The Iranian government doesn’t recognize being trans as a category per se, rather they see trans individuals as people with psychosexual problems, and so provide them with a medical solution,” says Kevin Schumacher, a Middle East and North Africa expert with OutRight Action International, a global LGBTIQ-rights organization. The policy is based on Islamic notions that gender is binary and that social responsibilities should be split between men and women. “If you’re born a man and your body is a female then in order to protect you and the wellbeing of society,” says Schumacher says, “the government is responsible for fixing the issue.”

An uncomfortable truth

For Sarah, life in Iran was divided into two very distinct parts: before and after she had gender confirmation surgery.

As a young child growing up in the late 1980s in Tehran, Sarah (who, because she is not openly trans, did not want to publish her full name) was uncomfortable wearing the clothes and playing the games traditionally associated with being a boy, and felt she did not belong at the all-boy’s school to which her parents sent her. “You are alone against all the social norms that dictate what you should do, what you should wear, how you should live,” she says.

She was a good student, but in high school, when puberty hit and gender roles grew starker, Sarah began to have difficulty coping with schoolwork and dropped out. “I had to deal with sexual harassment from my classmates and from other people in society on a daily basis, from everyone that thought that [I] was a girlish boy, a sissy boy,” she says. “My life as a teenager was total hell.”

Despite the official policy about trans individuals, trans issues are not openly discussed in Iran. And because the government heavily censors material available on the internet ( a 2013 analysis found that nearly half of the 500 most popular sites on the internet are blacklisted in Iran) Sarah couldn’t research what it means to be transgender or connect with others in the community.

Meanwhile, she felt guilty about her inability to fit in. “Everybody expected me to behave like a man and be like a man and I hated to be like that,” she says. “I wondered why I couldn’t be like other people. Why I couldn’t meet the social expectations.”

At 16, she decided to make a change. “If I’m not a woman, if I’m not a man, I thought at least I should be a productive person and live a…happy life,” she says. So she enrolled in university in Tehran, and began to study languages and translation skills. Even though she continued to live as a man, she grew more confident in her gender identity thanks to the more tolerant atmosphere at the university, and from her academic successes—though she was still years away from realizing she was trans.

The official view

Officially, an Iranian can be diagnosed as having gender identity disorder only after a complex series of medical tests and legal procedures including obtaining a court order, multiple visits to a psychiatrist, and physical and psychological examinations at the state’s Legal Medicine Organization. Even if you somehow figure out how to navigate this process—and Sarah did not—it can take over a year, according to a report compiled by OutRight Action International, a global LGBTIQ-rights organization.

When people do approach doctors in Iran about being transgender, the experience is not always pleasant or helpful. Amir, a 26-year-old trans man from Shiraz, Iran, told OutRight that when he approached a medical professional about his condition, the doctor tried to intimidate him:

It all started when I was eight or nine years old. My parents took me to see a doctor because I kept saying I was a boy. The doctors never talked to me. They just told horrible and terrifying stories to shut me up. They said things like “you will die if you undergo [sex reassignment surgery],” or “many girls who wanted to become boys died during the surgery”

All of them treated me like I was delusional…. They would tell me: “It’s not possible, you were born like this.” But I knew I had to do this operation and change my sex. I was convinced there was a way and I was just looking for some kind of confirmation, from someone, who would tell me “yes, it’s possible!” Instead, one of the doctors gave me pills, and another other one injections…. [Another] told me to “get out and close the door behind [me],” as if I was a dirty and untouchable person.

If an Iranian is officially diagnosed with gender identity disorder, the government issues the authorization for them to legally start the sex reassignment process, and at the end of that process the court issues a new identity card, with a new gender listed. In other words, while Iran does not mandate that all trans individuals have the surgery, it is not possible to change your gender marker on official documents without undergoing the surgery.

Over the last decade, with high-profile clerics and academic centers advocating for trans rights, social awareness on the issue has grown, says Schumacher. In 2007, Molkara established the Iranian Society to Support Individuals with Gender Identity Disorder, the first legally registered trans advocacy group. In 2008, the BBC reported that Iran was second only to Thailand in the number of sex-change operations performed, and the country’s surgery industry still attracts patients from all over the Middle East and Eastern Europe. Between 2006 and 2014, nearly 1,400 people applied for permission for the process according to government figures published in Iranian media.

There are even Iranian movies about accepting trans identities: 2012’s Facing Mirrors was something of a social turning point, giving local journalists a chance to address the issue publicly.  The film’s release was even covered by state-run television and radio channels.

Nevertheless, stigmas remain, reinforced by the notion perpetuated by the government that being trans is a medical problem. Outright’s report found that trans individuals are often subjected to bullying, domestic violence, and social discrimination. In some cases, family members disown trans relatives. Openly trans people often can’t get jobs, and when employers find out an employee is trans they are often fired. Trans individuals can’t rent houses or apartments easily and find it hard to get married because families don’t welcome the idea of having a trans son- or daughter-in-law.

All of which is why when Sarah finally realized that she was trans, when she was in her early 20s and already graduated from college, she did not feel comfortable coming out in public. “Only my family members and few of my close friends knew about it,” she says. “I had to hide everything.”

Making the decision to go through with gender-confirmation surgery was fraught with uncertainty. “On one hand I really wanted to do that and be free and liberated from all the problems of my past,” says Sarah. “On the other hand I was so scared of the ramifications of what I was going to do, because I thought I [would] lose everyone and everything that I had fought for. My university degree, my job, everything. I saw myself having to stand against the entire world.”

Practically, she did not have the means to go through with the surgery and live independently. According to OutRight’s report , the cost of the gender-confirmation surgery in Iran is $13,000 and hormone-replacement therapy costs $20-$40 a month—and the average Iranian’s monthly income is about $400.

The government does offer some limited financial support for gender-confirmation surgery, hormone-replacement therapy, and psychosocial counseling. But funds are limited and government officials decide on a case-by-case basis which individuals qualify. In 2012, the government announced that health insurance companies must cover the full cost of sex-change operations, according to a BBC report . But OutRight has found that insurance companies still often decline to cover some forms of transition-related care, on the basis that they are cosmetic and not medical.

“The government pays a lot of lip service but the actual services that they provide are extremely limited,” says Schumacher. “You talk to many people and they tell you that they have been waiting for many years, hoping to receive some government assistance for these medical bills, but they are still waiting.”

The challenges of being trans in Iran

For those who don’t get the surgery, life in Iran is exceedingly difficult.

Sharia-based laws mandate segregation of men and women in schools and public transport, and Iranian law requires men and women to wear “gender-appropriate” clothing in public spaces. Women are expected by law to wear a hijab , which means they must dress modestly and cover their head, arms, and legs. Traditionally, this is interpreted as a long jacket, called a manteau, accompanied by a headscarf. Failure to conform to this is a crime and could result in arrest or assault at the hands of vigilantes.

“If their appearance is not completely male or female, they are even stopped in the streets by the moral police in Iran,” says Saghi Ghahreman, president of the Iranian Queer Organization based in Canada. These are the undercover agents deployed by the police to patrol public spaces looking for men and women dressed or behaving in a manner deemed un-Islamic, The Guardian reported in 2016. The moral police crack down on loose-fitting headscarves, tight overcoats, shortened trousers for women and necklaces and shorts for men.The laws are often extended to cover new fashions. For instance in 2010 Iran banned ponytails, mullets, and long, gelled hair for men; in 2015 the country cracked down on “homosexual” and “devil worshiping” hairstyles along with tattoos, sunbed treatments, and plucked eyebrows for men.

Hasti, a 30-year-old Iranian trans woman from Khansar, told OutRight that she was frequently harassed by Iranian police for her feminine appearance and makeup. “The [police] would lift up my dress, look at my ID card and ask me if I was a man or a woman,” she said. “In the end they would force me to sign a pledge letter [to promise that I would no longer dress as a woman] and then release me.”

Because women are expected to get married at a young age and produce children, trans people who have not gone through the surgery are sometimes forced into marriage.

Worse, a trans person who is not legally recognized can be accused of homosexuality and face the death penalty. In fact, in some cases gay people in Iran decide to undergo the surgery because the alternative is death. “The sex change operation is most of the time forced on trans people by the culture and by the government,” says Ghahreman.

Making the transition

Sarah spent six years preparing mentally and financially to go through with the surgery.  She describes that period as one of the darkest phases of her life. “I was so depressed and anxious about everything,” she says. “At that time almost all the transgender people I saw in Iranian society were involved in prostitution, were isolated, were ostracized by the society and their family. I didn’t see any successful transgender people. I was afraid if I did it myself, my life would turn into a kind of new misery.”

But she stuck with the plan: she worked in a managerial job, living and dressing like a man, while saving for the surgery. When she had enough money, she decided to travel to Thailand for the surgery; despite the high number of gender confirmation surgeries performed in Iran, the quality of the work is poor. “The operations are done by surgeons that are not professionally trained,” says Ghahreman. “Almost all of the trans people who have operations in Iran are suffering from many side effects that disable their body. Every trans person I have met in the past 10 years, they have a lot of pain because of the surgery and they cannot have normal or pleasurable intercourse.”

When she was 28, Sarah had sex reassignment surgery. “I turned into a whole new version of myself which I loved so much,” she says, likening the process to dying and being reborn. I felt more liberated than what I was in the past. Because in the past I was imprisoned within the framework of my body and my former identity. After the surgery, I got liberated from all those things. For me, anything was better, anything. At least after the surgery I got to enjoy some basic rights that I didn’t enjoy before the surgery.”

Afterwards, she was surprised to find that “almost everyone was very welcoming and very supportive.” Sarah had worried government officials would harass her during the legal process after the surgery, but “everyone treated me like a saint,” she says. “They adore me so much and they admire me so much for doing such a courageous thing—they respect me on a whole different level. I didn’t even expect that—to be respected by people for being a transgender. But it all happened after the surgery.” And, all of a sudden, she could wear the clothes she wanted, change her name, and live the lifestyle of her choice.

Not everyone has such a positive experience with Iranian officials. Assal, a trans woman who travelled back from Iran after undergoing the surgery in Thailand told OutRight she was harassed by Iranian border police agents who passed around her medical documents to each other and laughed at her.  “I felt I was a monkey at the zoo,” she told OutRight.

And despite the support, Sarah never came out officially. Instead, she began to live as a woman in Iran. “The people who know me from the past, they know that I am a transgender, but the people who know me after the surgery, they have no idea of who I was,” she says. “They just think that I am a straight woman.”

Sarah stayed in Iran for six years after surgery. Now 36, she lives in Canada and works as a freelance journalist and translator. But she returns to the country of her birth frequently, and helped found an organization for trans rights there with Maryam Khatoon Molkara. “The culture needs to change,” says Sarah. “The society needs to change its mindset towards people who not like the mainstream. It doesn’t matter if they are gay, bisexual, or trans.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reforms will save lives, advocate says

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

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

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

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

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

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

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

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

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

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

"That is what is widely considered best practice."

More change to come

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

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

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

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

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

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

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

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

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

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

Reform follows landmark UK review

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

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

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

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Ohio judge temporarily blocks ban on gender-affirming care for transgender minors

A Franklin County judge on Tuesday temporarily blocked an impending law that would restrict medical care for transgender minors in Ohio.

The decision came weeks after the American Civil Liberties Union filed a lawsuit challenging House Bill 68 on behalf of two transgender girls and their families. The measure prevents doctors from prescribing hormones, puberty blockers or gender reassignment surgery before patients turn 18.

Attorneys contend the law violates the state Constitution , which gives Ohioans the right to choose their health care.

"Today's ruling is a victory for transgender Ohioans and their families," said Harper Seldin, staff attorney for the ACLU. "Ohio's ban is an openly discriminatory breach of the rights of transgender youth and their parents alike and presents a real danger to the same young people it claims to protect."

House Bill 68 was set to take effect April 24 after House and Senate Republicans  voted to override  Gov. Mike DeWine's veto. Proponents of the bill contend it will protect children, but critics say decisions about transition care should be left to families and their medical providers.

The suit in Ohio mirrors efforts in other states to challenge laws that restrict gender-affirming care for minors. A federal judge struck down a  similar policy in Arkansas , arguing it violates the constitutional rights of transgender youth and their families. The state is appealing that decision.

“This is just the first page of the book,” Attorney General Dave Yost said Monday. “We will fight vigorously to defend this properly enacted statute, which protects our children from irrevocable adult decisions. I am confident that this law will be upheld.”

What does House Bill 68 do?

House Bill 68 allows Ohioans younger than 18 who already receiving hormones or puberty blockers to continue, as long as doctors determine stopping the prescription would cause harm. Critics say that's not enough to protect current patients because health care providers could be wary of legal consequences.

The legislation does not ban talk therapy, but it requires mental health providers to get permission from at least one parent or guardian to diagnose and treat gender dysphoria.

The bill also bans transgender girls and women from playing on female sports teams in high school and college. It doesn't specify how schools would verify an athlete's gender if it's called into question. Players and their families can sue if they believe they lost an opportunity because of a transgender athlete.

The lawsuit doesn't specifically challenge the athlete ban. But it argues that House Bill 68 flouts the constitution's single-subject rule, which requires legislation to address only one topic. House Republicans introduced separate bills on gender-affirming care and transgender athletes before  combining them into one .

In Tuesday's decision, Franklin County Judge Michael Holbrook indicated that the law could be tossed out because of a single-subject violation.

"It is not lost upon this Court that the General Assembly was unable to pass the (Saving Ohio Adolescents from Experimentation) portion of the Act separately, and it was only upon logrolling in the Saving Women’s Sports provisions that it was able to pass," Holbrook wrote.

Panel clears ban on gender reassignment surgery for minors

Tuesday's decision came one day after a legislative panel cleared the way for an administrative rule that will ban gender reassignment surgery for minors. Ohio health care providers say they do not perform that procedure on patients under 18.

The rule will take effect May 3.

The measure was among several that DeWine proposed to regulate gender-affirming care after he vetoed House Bill 68. In testimony for Monday's meeting, opponents argued that the rules overstep the administration's authority and conflict with federal law.

"The proposed administrative rule changes are based on biased definitions, ignore well-established best practices and restrict countless patients’ access to gender-affirming care," said Mallory Golski, civic engagement and advocacy manager for Kaleidoscope Youth Center.

DeWine's other proposals are still working their way through the rulemaking process. That includes a requirement for transgender minors to undergo at least six months of counseling before further treatment occurs. Another rule would require providers to report non-identifying data on gender dysphoria diagnoses and treatment.

Haley BeMiller is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

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NOTICE: Transgender support groups come and go. Individual contacts, e-mail addresses and phone numbers are sometimes changed. We attempt to provide the most current information, however, we suggest that you might want to search a little more at your favorite search engine to verify the existence and correct contact information for any transgender support groups or resources listed here. If you know of any California transgender support groups that should be listed, edited or deleted, please post the updates in comments at the bottom of this page for the fastest response.

3rd Sect c/o Sacramento Gender Association PO Box 215456 Sacramento, CA 95821-1456 FTM support group.

Alpha Chapter, Tri-Ess PO Box 411532, Eagle Rock Sta. Los Angeles, CA 90041 http://www.transgender.org/alpha/alpha.htm Support group for hetero CDs and their SO’s, or families

American Transsexual Education Center 1626 N. Wilcox Ave. #584 Hollywood, CA 90048 (213) 467-8317 Professional services, telephone crisis counseling for the transgender and transsexual community.

Androgyny PO Box 480740 Los Angeles, CA 90004 (213) 467-8317 Social and support group for those who crossdress.

Club Cherchez La Femme PO Box 14521 LongBeach, CA 90803 Private membership club for those who appreciate the drag scene. Monthly dance party.

C.H.I.C. 8502 E. Chapman Ave. #425 Orange, CA. 92869 Information line 1-(714)-812-3236 E-mail: [email protected] Support and friendship for heterosexual CDs.

CD Social Group PO Box 224 Montrose, CA 91021 A group free of politics, write for information.

Changeling 127 Collingwood San Francisco, CA (415) 703-6150 (ext 22) Social/support group for TG/TS/CD, 25 & under.

Diablo Valley Girls PO Box 272885 Concord, CA 94527-2885 (925) 937-8432 http://www.transgender.org/tg/dvg/ Informal social support group with open membership.

Desert Transgender Alliance P.O. Box 391, Thousand Palms, CA 92276 (760) 318-7973 http://deserttransgenders.s5.com/ Transgender support, social activities and therapy service.

East Bay Transgendered Alcoholics Anonymous 3989 Howe St. @ Mandana House, 1 block from Kaiser off Broadway Oakland, Ca 94611 Meets weekly on Thursdays 8 – 9 pm

Far West Women Eureka, CA [email protected] TG support group. Occasional potlucks, activities, etc.

FTM International 160 14th St. San Francisco, CA 94103 (415) 553-5987 (voicemail) http://www.ftmi.org Support group for FtM crossdressers, TSs, and their SO’s.

FPSG 584 Castro / PO Box 410-990 San Francisco, CA 94141-0990 Support group for FTM TSs of COLOR ONLY. Meetings dealing with crossliving.

Free to be Me 1900 E. 4th Street. Santa Ana, CA 92705 (714) 223-2600 TG Support Kaiser. Wednesdays at 4.30pm

Gender Expressions PO Box 816 Lakewood, CA 90714-0816 (310) 869-4241 Outreach for TG people and their families.

Gender Awareness League PO Box 46062 Los Angeles, CA 90046 An open membership group for all individuals and friends dealing with gender issues.

Genderqueer Boyzzz Santa Barbara, CA [email protected] Social group for and about people born female who have masculine self-identifications.

LA Gay & Lesbian Center Ed Gould Plaza at The Village 1125 N. McCadden Place Los Angeles, CA 90038 (323) 860-7335 Office (323) 308-4179 Fax (323) 974-5926 Cell TG Women’s Group every other Friday from January 27th, 2006. http://www.trans-unity.com

Ladies Knight Out http://www.ladiesknightout.com Email: [email protected] Meets usually on the 1st of each month

LGBTQ Youth Space 938 he Alameda San Jose, CA www.youth.defrank.org Email: [email protected] (408) 293-3040 ext 107

Los Angeles Gender Center 1923 1/2 Westwood Blvd. Ste. 2 Los Angeles, CA 90025 (310) 475-8880 http://www.lagendercenter.com/ Professional gender treatment services.

Mariposa of Palm Springs (TG Outreach) 68277 Farnrell Lane Cathedral City, CA 92234 (909) 278-0500 Monthly meetings for TGs, their family & friends.

MCC TS Support Group c/o Metropolitan Community Church S. 7th St. San Jose, CA For TS (MtF & FtM) and SO & family members.

Nadia Cabezas 191 Golden Gate Ave. San Francisco, CA 94102 (415) 567-2346 Support group for TSs, their friends and family.

Neutral Corner PO Box 19008, San Diego, CA 92159 (619) 685-3696 http://www.geocities.com/WestHollywoo/4718/ A self-help support group for crossdressers and transsexuals.

On the Scene Night 1856 Cherry #608 Long Beach, 90806 Open parties for ladies to come out and meet friends.

Pacific Center for Human Growth (Satellite Office) 1250 Pine St. Walnut Creek, CA 94596 (510) 939-7711 Peer support/discussion groups for TG persons.

Phoenix Rising c/o Kristen Dixon PO Box 632852, San Diego, CA 92163-2852 Support/social group for transsexuals in transition

PSGV Transgendered Support 401 S. Main St., Ste. 104 Pomona, CA 91765 (909) 620-8987 Support group for all MtF, FtM transgenderists.

Rainbow Gender Association PO Box 700730 San Jose, CA 95170-0730 (408) 984-4044 (voicemail) http://www.transgender.org/tg/rga/rgapage.html Open social/support group for TSs and TVs.

Redwood Empire Social Group PO Box 1531 Sonoma, CA 95476 (707) 938-8029 CD/TS support group.

River City Gems The River City Gems are a 501(c)(3) nonprofit organization. We are a socialand support group serving the crossdressing and transgender community of Northern California. We are based in Sacramento and have many members from the Central Valley, the Bay Area, the Sierra Nevada, and neighboring states. For verification and more details please visit our website. http://www.rivercitygems.org

Sacramento Gender Association PO Box 215456 Sacramento, CA 95821-1456 (916) 482-7742 Social, recreational, educational TG organization.

San Joaquin Gender Association 1141 Catalina Dr., Box 163 Livermore, CA 94550 (510) 447-9920 CD/TS/SO support group.

San Francisco Gender Information (SFGI) PO Box 423602 San Francisco, CA 94142-3602 Database of transgender resources for the San Francisco area.

Sigma Delta Gamma, Tri-Ess P.O. Box 2231, Carmichael, CA 95609 (916) 359-2328 http://www.geocities.com/Sigma_Delta_Gamma

Sigma Sigma Beta, Tri-Ess (Silver City Belles) PO Box 19933 S. Lake Tahoe, CA 96151 Support group for heterosexual crossdressers.

Society for the Second Self (Tri-Ess) National HQ PO Box 194 Tulare, CA 93275 Non-profit organization for heterosexual CDs & SOs.

Stonewall Alliance Center TG Support Chico, CA (916) 893-3336 Transgender resources center and support group.

Swan’s Inner Sorority (Society) PO Box 1651 San Jose, CA 95109 (408) 297-6900 http://www.sisgirls.com/ Sisterhood of TG individuals exploring the feminine.

TGIF Santa Rosa, CA (707) 544-1540 http://www.transgender.org/tg/tgif/ Support group for transgender, family, and friends.

TGSF PO Box 42602 San Francisco, CA 94142-64861 (415) 564-3246 http://www.transgender.org/tg/etvc/ An open support group for TVs and TSs.

Tenderlion Self-Help Center 191 Golden Gate Ave. San Francisco, CA 94102 (415) 554-0518 Peer counseling and support group.

Thursday Irregulars c/o Joan Sheldon PO Box 6541 San Jose, CA 95150-6541 Lunch meeting for TVs and friends.

TransBay 1234 Polk St. San Francisco, CA http://www.transbay.org/ Social gatherings for a diverse body of transfolks in the San Francisco Bay area.

Transmale Taskforce 1259 El Camino Real #151 Menlo Park, CA 94025 (415) 780-9349 FtM TS/TG support group.

TransFamily San Diego, CA (800) 666-8158 A support group for transgender people.

Transsexual Explorer Los Angeles, CA (323) 654-1454 Monthly group for m2f post & pre-op.

TransPowerment 100 North Winchester Boulevard Suite 250 Santa Clara, CA 95050 (408) 556-5506 extension 218 (408) 556-5517 Fax Contact: Danielle R Anderson-CastroTG Group catering to multicultural transgender community. The group meets every third Friday of each month from 6:00 – 8:00 p.m. Case management and free food available.

Transsexual Support Group 2017 E. 4th St. Long Beach, CA 90814 (310) 434-4455 (Stacy) Support/information for transsexuals and their loved ones.

Trans Thrive 1460 Pine Street San Francisco, CA 94109 http://www.sfcommunityhealth.org/transthrive [email protected] 415-292-3415 Mon-Fri 2:00p-4:30p Wrap around drop-in wellness center that provides resources and programs for all Trans and GNC individuals 13yrs+

Under Construction PO Box 922342 Sylmar, CA 91392 (818) 837-1904 (Jeff Shevlowitz) FTM organization.

California Transgender Nightclubs and Bars

A directory of transgender friendly nightclubs and bars in California for those who like to get out on the town to mingle. TGGuide TG Nightclubs Directory

Transgender ID Change in California

California State ID Change

If the change is due to transition, a new copy of DL-328 must be submitted for each driver license or identification card renewal, or upon any card issuance when the date of application (for a renewed card) is more than five years after the physician certification date. (in the DL-328 form) If a new form DL-328 is not submitted as specified, the original gender marker will be restored.

To apply for a name change you will need to:

• Visit a DMV office (make an appointment for faster service)
• Complete a Driver License or Identification Card Application form DL 44 or DL 44C. (Copies will not be accepted.)
• Give a thumbprint
• Have your picture taken
• Pay the application fee ($22, No fee for a senior citizen ID card)

Acceptable evidence of your new name may be provided by showing an original or certified copy of a  Birth Date/Legal Presence  document or a  true full name document .

Examples of a “true full name document” include:

• Adoption documents that contain the legal name as a result of the adoption.
• A name change document that contains the legal name both before and after the name change.
• Marriage certificate (issued from a local or state Office of Vital Statistics).
• A certificate, declaration, or registration document verifying the formation of a domestic partnership.
• Dissolution of marriage document that contains the legal name as a result of the court action.
• A completed Medical Information Authorization form (DL 328) in conjunction with a gender change.

This document must be issued by a government agency within the United States or a foreign jurisdiction that is authorized to issue such documents. The document must be a legible and unaltered original or certified copy with a government seal, stamp or other official imprints. You will need to surrender your current driver license and/or ID card.

California Birth Certificate Change

California will change both name and sex and will issue a new birth certificate rather than amend the old one. CA Health and Safety Code, Section 103425-103445, states: “A petition for the issuance of a new birth certificate in those cases shall be filed with the superior court of the county where the petitioner resides.”

The State Office of Vital Records has made a Web link with a PDF document detailing the procedure for obtaining a new birth certificate after “gender reassignment.” There is also a phone number for information on this procedure: (916) 557-6076

You will need an original letter from your SRS surgeon, and a certified copy [not the original!] of the court order for your name change. If you do not have a court order for your name change, you may petition the court for a change of name at the same time you petition for the new birth certificate. You will need a complete VS-24 form, which can be obtained from the State Office of Vital Records. A photocopy of this form is not sufficient.

A fee of $20 includes one copy of the new Birth Certificate; additional copies are $14 each.

California Center for Health Statistics

Michael Rodrian State Registrar and Chief Center for Health Statistics [email protected]

California Transgender Dating: Meet Trans Women & Trans Men

– California Transgender Personals –

Looking to meet transgender friends or lovers in California? You’ll find many local t-girls and admirers looking to connect with others for friendship and relationships. Our site is new but it already has more California TG Personals than any other transgender personals site on the Internet. Place a FREE photo ad , get noticed, and let them come to you. Discover your special connection here! Using the internal mail system, you’ll remain totally anonymous and discreet until you’ve met someone special and you’re ready to reveal more about yourself.

Transgender Support Groups Directory Updates

Please help us keep the California Transgender Support Groups page up-to-date. If you know of any trans support groups that should be listed, edited or deleted please comment below.

7 thoughts on “California”

I’m having trouble with my meds and seem to be confused

You will find a great transgender resource center at the Los Angeles LBGT Center. Info at https://lalgbtcenter.org/social-service-and-housing/transgender/support

I need to find a group that will put pressure on the imperial County sheriffs Department to investigate the death of a transgender friend of mine. A person is admitted to killing her by dragging her and leaving here in the desert in a car to make it look like an accident. I gave this info to the police but they don’t seem to be wanting to do anything. Can you direct me to where I should go for this help.

Hello Jay. Sincere condolences on the loss of your friend.

It is possible the Imperial County Sheriff’s Office is still conducting an investigation and is not at liberty to discuss the case. However, here are some sources that could possibly provide help.

The U.S. Department of Justice maintains a Civil Rights Division. Info at https://civilrights.justice.gov/ . Provided the details mentioned are accurate then there is a good chance this is a transgender hate crime which would fall under the purview of the Department of Justice.

Another possible source for assistance is to contact the California Attorney General’s Office. Info at https://oag.ca.gov/

There is also a list of transgender legal services at https://transequality.org/issues/resources/trans-legal-services-network-directory .

We’re updating Transgender Support Groups in California and we need your help. You may provide updated information on groups we have listed or feel free to add new transgender support groups in the comments below. Please share local resources to help transgender people find support services in California.

Thank you for the California Transgender Support Groups update! We have updated the listing with the information you provided.

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Sweden passes law to make it easier to change legal gender

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Israeli PM Netanyahu says he will fight any sanctions on army battalions

Israeli Prime Minister Benjamin Netanyahu said on Sunday he would fight against sanctions being imposed on any Israeli military units after media reported that Washington was planning such a step against a battalion for alleged rights violations.

Transgender women on 'Drag Race'? RuPaul's remarks spawn backlash

It's not often that the world's most famous drag queen loses control of her court, but RuPaul's recent comments on possibly excluding transgender contestants from VH1's "RuPaul's Drag Race" had several former contestants of the drag competition show speaking up against him. He eventually apologized.

RuPaul made the offending remarks in a recent interview with The Guardian. The Emmy-winning host was asked if he would allow "bio queens," a controversial term referring to cisgender (non-transgender) women on the show.

“Drag loses its sense of danger and its sense of irony once it’s not men doing it, because at its core it’s a social statement and a big f-you to male-dominated culture,” RuPaul said. “So for men to do it, it’s really punk rock, because it’s a real rejection of masculinity.”

The conversation then turned to whether transgender women who had undergone gender affirmation surgery, such as breast augmentation, could compete in the show. After all, a popular contestant from season nine, Peppermint, is a trans woman who was open about her identity during her run for the crown.

https://www.instagram.com/p/BdDx-M6HnXN

RuPaul noted that Peppermint did not get breast implants until after the show. When asked if he would accept a queen who already had them, RuPaul said "probably not."

"You can identify as a woman and say you’re transitioning, but it changes once you start changing your body," he said. "It takes on a different thing; it changes the whole concept of what we’re doing."

Backlash was swift on social media, and spearheaded by former contestants of the show. Gia Gunn, who competed on season six of "Drag Race" before she came out as trans, said that while she feels there is separation between being a drag queen and being a trans woman, anyone can be a drag artist.

Although I do feel the separation from being a drag queen and now a trans woman, there should not be any reason to be “not accepted” when it comes to the art of drag. If you are a fierce artist, your a fierce artist & should be judged based on your art. NOT your gender identity! — Gia Gunn (@GiaGunn) March 5, 2018

Jiggly Caliente, who competed in season four and later came out as trans, said there was "a revolution amongst the rebels" brewing in the wake of RuPaul's comments.

There's a revolution amongst the rebels. Pay attention !!! We refuse to stay marginalized and held down while you chose who to take up with you. #blend #thotprocess #transpower @Peppermint247 kudos to your song. It's timely and very relavant to our times. #transrevolution — Jiggly Caliente (@JigglyCaliente) March 4, 2018

Season nine's reigning queen, Sasha Velour, also weighed in, saying her drag was created in a community of trans men, trans women and gender-nonconforming people.

My drag was born in a community full of trans women, trans men, and gender non-conforming folks doing drag. That’s the real world of drag, like it or not. I thinks it’s fabulous and I will fight my entire life to protect and uplift it. — Sasha Velour (@sasha_velour) March 5, 2018

BenDeLaCreme, who recently made shockwaves in the "Drag Race" fandom by eliminating herself from season three of "All Stars" after a slew of challenge wins, also spoke up, saying her partner is transgender.

My partner of almost three years is trans, and #bendelachrist help anyone who tries to tell him what he can and can’t do. Just sayin’. — bendelacreme (@bendelacreme) March 5, 2018

Peppermint, however, did not address RuPaul's remarks directly. Instead, she tweeted a string of emojis, including a face with zipped-up lips.

🤐! — Peppermint (@Peppermint247) March 4, 2018

At first, RuPaul doubled down on social media. "You can take performance enhancing drugs and still be an athlete," he tweeted on Monday. "Just not in the Olympics."

You can take performance enhancing drugs and still be an athlete, just not in the Olympics. pic.twitter.com/HkJjzXzUGm — RuPaul (@RuPaul) March 5, 2018

However, he quickly reversed his position. "Each morning I pray to set aside everything I think I know, so I may have an open mind and a new experience," he tweeted later that same day. "I understand and regret the hurt I have caused. The trans community are heroes of our shared LGBTQ movement. You are my teachers."

Each morning I pray to set aside everything I THINK I know, so I may have an open mind and a new experience. I understand and regret the hurt I have caused. The trans community are heroes of our shared LGBTQ movement. You are my teachers. pic.twitter.com/80Qi2halN2 — RuPaul (@RuPaul) March 5, 2018

"In the ten years we've been casting Drag Race, the only thing we've ever screened for is charisma uniqueness nerve and talent," RuPaul wrote in another tweet, referring to the criteria for winning "Drag Race." "And that will never change." Attached to the tweet is "Train Landscape," an abstract piece by artist Ellsworth Kelly.

In the 10 years we’ve been casting Drag Race, the only thing we've ever screened for is charisma uniqueness nerve and talent. And that will never change. pic.twitter.com/0jsyt6MRvO — RuPaul (@RuPaul) March 5, 2018

Some have speculated this abstract image is RuPaul's attempt to convey things may be more complex than they appear. Others, however, have surmised RuPaul accidentally Googled "trains flag" instead of "trans flag" (which consists of pink, blue and white stripes) and shared the wrong image.

While "RuPaul's Drag Race All Stars 3" is still in progress, it will be immediately followed by the March 22 debut of season 10 of "RuPaul's Drag Race," featuring an entirely new crop of queens. As to whether or not RuPaul will ever have a transgender queen who has undergone gender affirmation surgery, audiences will have to wait until at least season 11.

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Sweden’s parliament passes a law to make it easier for young people to legally change their gender

A view of the Swedish Parliament as lawmakers vote on the new gender identity law, in Stockholm, Wednesday, April 17, 2024. The Swedish parliament passed a law Wednesday lowering the age required for people to legally change their gender from 18 to 16. Young people under 18 will still need approval from a guardian, a doctor, and the National Board of Health and Welfare. The government of Prime Minister Ulf Kristersson has been split on the issue.(Jessica Gow/TT News Agency via AP)

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COPENHAGEN, Denmark (AP) — The Swedish parliament passed a law Wednesday lowering the age required for people to legally change their gender from 18 to 16. Those under 18 still need approval from a guardian, a doctor and the National Board of Health and Welfare.

No longer required is a gender dysphoria diagnosis, defined by medical professionals as psychological distress experienced by those whose gender expression does not match their gender identity.

Sweden joins a number of countries with similar laws including Denmark, Norway, Finland and Spain .

The vote in Sweden passed 234-94 with 21 lawmakers absent, following a debate that lasted for nearly six hours.

Sweden Democrats, the populist party with far-right roots that supports the government in parliament but is not part of the government, opposed the law.

Jimmie Akesson, leader of the Sweden Democrats, told reporters it was “deplorable that a proposal that clearly lacks the support of the population is so lightly voted through.”

But Johan Hultberg with the Moderates of Sweden’s conservative prime minister, Ulf Kristersson, called the outcome “gratifying.” Hultberg called it “a cautious but important reform for a vulnerable group. I’m glad we’re done with it.”

Kristersson’s center-right coalition had been split on the issue, with the Moderates and the Liberals largely supporting the law while the small Christian Democrats were against it.

Peter Sidlund Ponkala, chairman of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights, known by its Swedish acronym RFSL, called the law’s passage “a step in the right direction” and “a recognition for everyone who has been waiting for decades for a new law.”

Elias Fjellander, chairman of the organization’s youth branch, said it would make life better for its members. “Going forward, we are pushing to strengthen gender-affirming care, to introduce a third legal gender and to ban conversion attempts,” Fjellander said in a statement.

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

In the U.K., the Scottish parliament in 2022 passed a bill allowing people aged 16 or older to change their gender designation on identity documents by self-declaration. It was vetoed by the British government, a decision that Scotland’s highest civil court upheld in December . The legislation set Scotland apart from the rest of the U.K., where the minimum age is 18 and a medical diagnosis is required.

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Supreme Court Clears Way, for Now, for Idaho to Ban Transgender Treatment for Minors

The Idaho attorney general had asked the justices to move swiftly to let the state law, which would ban gender-affirming medical care for minors, go into effect.

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By Abbie VanSickle

Reporting from Washington

The Supreme Court temporarily allowed Idaho on Monday to enforce a ban on gender-affirming treatment for minors, effectively suggesting that some justices appear comfortable with wading into another front in the culture wars.

In siding with state officials who had asked the court to lift a block on the law as an appeal moves forward, the justices were sharply split, with a majority of the conservatives voting to allow the ban to take effect over the objections of the three liberals.

The court said the ban would apply to everyone except for the plaintiffs who brought the challenge.

Notably, the opinions focused not on transgender care, a hot-button political issue that has prompted several Republican-led legislatures to approve bills to restrict puberty-blocking drugs and hormone treatments, but on a broader legal question: universal injunctions.

Universal injunctions are when a single judge issues a sweeping decision that applies beyond those directly involved in the dispute. Some justices have signaled an interest in looking at the tactic.

Although orders in response to emergency applications often include no reasoning, the justices in this case divided into several factions.

The decision included concurrences by Justice Neil M. Gorsuch, who was joined by Justices Samuel A. Alito Jr. and Clarence Thomas, and Justice Brett M. Kavanaugh, who was joined by Justice Amy Coney Barrett. Chief Justice John G. Roberts Jr. did not note a position.

Justice Ketanji Brown Jackson dissented and was joined by Justice Sonia Sotomayor. Justice Elena Kagan noted a dissent.

The Idaho law, passed by the state’s Republican-controlled Legislature, makes it a felony for doctors to provide transgender medical care for minors, including hormone treatment.

States around the country have pushed to curtail transgender rights. At least 20 Republican-led states, including Idaho, have enacted legislation that limits access for gender transition care for minors.

In his concurrence, Justice Gorsuch said the use of a universal injunction “meant Idaho could not enforce its prohibition against surgeries to remove or alter children’s genitals, even though no party before the court had sought access to those surgeries or demonstrated that Idaho’s prohibition of them offended federal law.”

He wrote that the case broached the use of such injunctions, “a question of great significance that has been in need of the court’s attention for some time.” In recent years, he added, lower courts had overstepped their bounds by seeking “to govern an entire state or even the whole nation from their courtrooms.”

In her dissent, Justice Jackson also honed in on similar questions. But she wrote that the case, particularly given that it was brought on the emergency docket, was “not be the place to address the open and challenging questions that that issue raises.”

If there was any point of agreement in the case, it seemed to be a growing frustration with the number and scope of cases brought on the court’s emergency docket.

Justice Jackson noted that she saw “some common ground” with her conservative colleagues by agreeing that “our emergency docket seems to have become increasingly unworkable.”

The American Civil Liberties Union, which represents the plaintiffs in the case, denounced the outcome, saying it was “an awful result for transgender youth and their families across the state.”

“Today’s ruling allows the state to shut down the care that thousands of families rely on while sowing further confusion and disruption,” it said in a statement.

The Idaho attorney general, Raúl Labrador, a Republican and former member of Congress who helped found the conservative House Freedom Caucus, celebrated the decision.

“Denying the basic truth that boys and girls are biologically different hurts our kids,” Mr. Labrador said. “No one has the right to harm children, and I’m grateful that we, as the state, have the power — and duty — to protect them.”

Idaho officials had appealed to the Supreme Court after the U.S. Court of Appeals for the Ninth Circuit, in San Francisco, upheld a temporary block on the law as litigation continues in lower courts.

The law, the Vulnerable Child Protection Act, makes it a crime for medical providers to offer medical care to transgender teenagers.

Mr. Labrador, in his emergency application, said that the case raised a recurring question that a majority of the justices had expressed interest in: whether a court can enact a universal injunction.

Mr. Labrador contended that a federal court erred in applying the freeze so expansively. “The plaintiffs are two minors and their parents, and the injunction covers two million,” he wrote.

Temporarily barring the law meant “leaving vulnerable children subject to procedures that even plaintiffs’ experts agree are inappropriate for some of them,” he added.

Mr. Labrador continued, “These procedures have lifelong, irreversible consequences, with more and more minors voicing their regret for taking this path.”

The plaintiffs had asserted that the case was not the right vehicle for addressing concerns about universal injunctions.

That is because the four plaintiffs are anonymous, referred to only by pseudonyms. If the court narrowed the temporary pause on the Idaho law to apply only to those directly involved in the lawsuit, the plaintiffs, including minors, would be forced to “disclose their identities as the transgender plaintiffs in this litigation to staff at doctors’ offices and pharmacies every time they visited a doctor or sought to fill their prescriptions.”

Abbie VanSickle covers the United States Supreme Court for The Times. She is a lawyer and has an extensive background in investigative reporting. More about Abbie VanSickle