Category: Medical transition • Page 3
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Long-term testosterone use in natal females can cause vaginal atrophy, which makes sex painful
A study1 of 16 female-to-male transgender individuals concluded that long-term testosterone administration leads to vaginal atrophy (Baldassarre et al., 2013). The study noted that:
Vaginal samples from FtM showed a loss of normal architecture of the epithelium, intermediate and superficial layers were completely lost, and glycogen content was depleted.
Vaginal atrophy, characterized by thinning of vaginal walls and poor lubrication of vaginal tissues, leads to tearing, micro abrasions, bleeding, and painful intercourse.
- Baldassarre, M., Giannone, F., Foschini, M., Battaglia, C., Busacchi, P., Venturoli, S., & Meriggiola, M. (2013). Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women. International Journal Of Impotence Research, 25 (5): 172-177. [Link] ↩︎
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Medical transition puts both males and females at risk of infertility
A wide-ranging study1 found that gender-related drug regimens place patients at risk of infertility:
Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear.
On surgeries, the study noted that cross-sex surgery that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility.
- Cheng, P.J., Pastuszak, A.W., Myers, J.B., Goodwin, I.A. & Hotaling, J.M. (2019). Fertility concerns of the transgender patient. Transl Androl Urol. 8 (3): 209-218. [Link] ↩︎
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One study found that puberty blockers did not alleviate negative thoughts in children with gender dysphoria
A British study1 found that puberty blockers used to treat children aged 12 to 15 who have severe and persistent gender dysphoria had no significant effect on their psychological function, thoughts of self-harm, or body image.
However, as expected, the children experienced reduced growth in height and bone strength by the time they finished their treatment at age 16.
- Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS ONE 16 (2). [Link] ↩︎
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Puberty blockers and cross-sex hormones negatively impact bone health in a significant number of cases
There is little long-term evidence on bone mass density in relation to puberty blockers. However, in a significant minority of cases of long-term puberty suppression related to gender identity, bone mass density scores qualify as “low for age”1. Low bone mass density increases risk of osteoporosis and fractures.
Adolescents who enter puberty at an older age have persistently lower bone mass density than their peers2: in one case study3, an adolescent had a bone mass density -2 standard deviations below the mean after three years of blocking puberty.
It has also been noted4 that:
In early-pubertal transgender youth, BMD [bone mass density] was lower than reference standards for sex designated at birth. This lower BMD may be explained, in part, by suboptimal calcium intake and decreased physical activity–potential targets for intervention.
Bone metabolism is also decreased as a result of taking cross-sex hormones, for both males and (in later life) females5.
- Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology and Metabolism 34 (7): 937-939. [Link] ↩︎
- Elhakeem, A., Frysz, M., Tilling, K., Tobias, J.H. & Lawlor, D.A. (2019). Association Between Age at Puberty and Bone Accrual From 10 to 25 Years of Age. JAMA Netw Open; 2(8). [Link] ↩︎
- Pang, K.C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., Clark, B.A., Olson-Kennedy, J., Telfer, M.M. & Lantos, J.D. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics 145 (2). [Link] ↩︎
- Lee, J. Y., Finlayson, C., Olson-Kennedy, J., Garofalo, R., Chan, Y. M., Glidden, D. V., & Rosenthal, S. M. (2020). Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study. Journal of the Endocrine Society 4 (9). [Link] ↩︎
- Vlot, M.C., Wiepjes, C.M., de Jongh, R.T., T’Sjoen, G., Heijboer, A.C. & den Heijer, M. (2019). Gender-Affirming Hormone Treatment Decreases Bone Turnover in Transwomen and Older Transmen. J Bone Miner Res, 34: 1862-1872. [Link] ↩︎
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The chances of developing osteoporosis and cardiovascular problems increase with feminizing hormones
A 2012 paper1 found that a quarter of the male-to-female transsexuals it studied had osteoporosis at the lumbar spine and radius.
In the same study, 6% of male-to-female transsexuals experienced a thromboembolic event (a blood clot causing obstruction), and another 6% experienced other cardiovascular problems. These effects were observed after only 11.3 years of hormone treatment on average.
A further study2 found that long-term bone mineral density decreases in transwomen who take cross-sex hormones in the long term.
- Wierckx, K., Mueller, S., Weyers, S., Van Caenegem, E., Roef, G., Heylens, G. & T’Sjoen, G. (2012). Long-Term Evaluation of Cross-Sex Hormone Treatment in Transsexual Persons. The Journal of Sexual Medicine 9 (10): 2641-2651. [Link] ↩︎
- Delgado-Ruiz, R., Swanson, P., & Romanos, G. (2019). Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy. Journal of clinical medicine 8 (6): 784. [Link] ↩︎
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Female-to-male genital reconstruction surgery has a high negative outcome rate, including urethral compromise and worsened mental health
The results of a 2021 international survey1 of 129 female-to-male patients who underwent genital reconstruction surgery support anecdotal reports that complication rates following genital reconstruction are higher than are commonly reported in the surgical literature.
Complication rates, including urethral compromise, and worsened mental health outcomes remain high for gender affirming penile reconstruction. In total, the 129 patients reported 281 complications requiring 142 revisions.
Another paper2 found a 70% complication rate in one type of female-to-male genital reconstruction surgery.
Even with the “radial forearm free flap” method of creating a synthetic penis — “considered by many as the gold standard for phalloplasty”3 — there are high rates of complications, with up to 64% urethroplasty related complications4.
- Robinson, I.S., Blasdel, G., Cohen, O., Zhao, L.C. & Bluebond-Langner, R. (2021). Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 18 (4): 800-811. [Link] ↩︎
- Bettocchi, C., Ralph, D.J. & Pryor, J.P. (2005). Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 95:120–4. [Link] ↩︎
- Rashid, M. & Tamimy, M. S. (2013). Phalloplasty: The dream and the reality. Indian J Plast Surg 46 (2): 283-293. [Link] ↩︎
- Fang, R.H., Lin, J.T. & Ma S. (1994). Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery 15: 349–52. [Link] ↩︎
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There is little evidence that medical transition decreases suicidality
When it comes to gender dysphoric children, there is little evidence that medical transition decreases suicide rates. There is little evidence to assert that puberty blockers are necessary to prevent suicide1.
After sex reassignment surgery, one study showed that adult transsexual clients were 4.9 times more likely to have made a suicide attempt and 19.1 times more likely to have died from suicide, after adjusting for prior psychiatric comorbidity2. Similarly, an Australian paper3 notes that many patients have poor outcomes, which puts them at risk of suicide.
A prominent study4 claiming that medical transition alleviated suicidality had to be corrected5, to clarify that it proved “no advantage of surgery” in this regard.
A long-term Swedish study6 finds that post-operative transgender people have “considerably higher risks” for suicidal behavior.
Similarly, a study in the European Journal of Endocrinology7 demonstrates that suicide rates among transgender male-to-females were 51% higher than the general population.
- Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior (49): 2227–2229. [Link] ↩︎
- Zucker, K.J., Lawrence, A.A., Kreukels, B.P. (2016). Gender Dysphoria in Adults. Annu Rev Clin Psychol. 12: 217-47. [Link] ↩︎
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Bränström, R. & Pachankis, J. E. (2019). Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry 177 (8): 727-734. [Link] ↩︎
- American Journal of Psychiatry (2020). Correction to Bränström and Pachankis. Published online: 1 August 2020. [Link] ↩︎
- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). ‘Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden’. PLoS ONE, 6(2). [Link] ↩︎
- Asscheman, H., Giltay, E. J., Megens, J. A. J., de Ronde, W., van Trotsenburg, M. A. A. & Gooren, L. J. G. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology 164 (4). [Link] ↩︎
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There is evidence that all-cause mortality is higher among trans people than among the general population
A Swedish study1 found that sex-reassigned transsexual persons – both male and female – had approximately a three times higher risk of all-cause mortality than non-transsexuals. Elevated causes of mortality included cancer, cardiovascular disease, and violent crime:
This finding was backed up by a Dutch study2, which stated:
This observational study showed an increased mortality risk in transgender people using hormone treatment, regardless of treatment type. This increased mortality risk did not decrease over time.
- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS ONE, 6(2). [Link] ↩︎
- de Blok, C.J.M., Wiepjes, C.M., van Velzen, D.M., Staphorsius, A.S., Nota, N.M., Gooren, L.J.G., Kreukels, B.P.C. & den Heijer, M. (2021). Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology 9. [Link] ↩︎
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Studies on gender dysphoric young people often suffer from high rates of loss to follow-up – which could skew transition satisfaction rates
In one study1 of 77 pre-teen participants, 30% were lost to follow up by their teenage years: either they did not respond to the recruiting letter, or were not traceable. In another study2, as many as 75% of participants were lost to follow up.
An excellent précis of this problem can be found in a 2018 paper3, which gives further detail:
Smith et al. report that sex reassignment is effective, based on a study of 162 adults who had undergone SRS. They were able to obtain follow-up data from only 126 (78%) of subjects because a significant number were “untraceable” or had moved abroad.
De Cuypere et al. report that sex reassignment surgery is an effective treatment for transsexuals. Of 107 patients who had undergone SRS between 1986 and 2001, 30 (28%) could not be contacted and 15 (14%) refused to participate.
Johannson et al. reported good outcomes for SRS. Of 60 patients who had undergone SRS, 42 (70%) agreed to participate in the follow up research. Of the non-participants, 1 had died of complications of SRS, 8 could not be contacted and 9 refused to participate.
Salvador et al. reported that SRS has a positive effect on psychosocial functioning. Only 55 of the 69 patients (80%) could be contacted as 17 were lost to follow-up
Van de Grift et al. reported 94–96% of patients are satisfied with SRS and have good quality of life. A total of 546 patients with Gender Dysphoria who had applied for SRS at clinics in Amsterdam, Hamburg and Ghent were contacted to complete an online survey. Only 201 (37%) responded and completed the survey.
A good example of how this phenomenon can affect satisfaction and regret statistics comes from a 2018 paper4, which is often cited as proof of low regret rates. The loss to follow up rate in this paper is 36%. The authors also state:
In addition, in our population the average time to regret was 130 months, so it might be too early to examine regret rates in people who started with HT [hormonal treatment] in the past 10 years.
- Wallien, M.S. & Cohen-Kettenis P.T. (2008) Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 47 (12): 1413-23. [Link] ↩︎
- Rauchfleisch, U., Barth, D. & Battegay, R. (1998). Resultate einer Langzeitkatamnese von Transsexuellen. Der Nervenzart 69: 799-805. [Link] ↩︎
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Wiepjes, C.M., Nota, N.M., de Blok, C.J.M., Klaver, M., de Vries, A.L.C., Wensing-Kruger, S.A., de Jongh, R.T., Bouman, M.B., Steensma, T.D., Cohen-Kettenis, P., Gooren, L.J.G., Kreukels, B.P.C. & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Journal of Sexual Medicine 15 (4). [Link] ↩︎
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There is limited evidence that medical transition leads to positive outcomes
A number of different studies have noted the paucity of good quality evidence for transition.
An Australian paper1 states that most available evidence indicating positive outcomes for gender reassignment is of poor quality.
A German study2 “found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition”, adding that “[t]his lack of studies shows a gap between current clinical practice and clinical research.”
A British review3 conducted by the National Institute for Health and Care Excellence (NICE) graded certainty of evidence for puberty blocker use as “very low” in every category, including impact on gender dysphoria, mental health, body image, global functioning, psychosocial functioning, cognitive functioning, bone density and adverse effects.
A chapter4 in an edited volume details the low evidence base for treatment pathways employed at the UK’s Gender Identity Development Service, demonstrating how negative evidence was “ignored or suppressed”.
Finally, a systematic review5 commissioned by the World Professional Association for Transgender Health (WPATH) to “systematically review the effect of gender-affirming hormone therapy on psychological outcomes among transgender people” noted that, in some areas, there was low quality or insufficient evidence.
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Haupt, C., Henke, M., Kutschmar, A., Hauser, B., Baldinger, S., Saenz, S.R. & Schreiber, G. (2020). Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database of Systematic Reviews 11. [Link] ↩︎
- National Institute for Health and Care Excellence (2021). Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. National Institute for Health and Care Excellence (NICE); NHS England; NHS Improvement. [Link] ↩︎
- Biggs, M. (2019). The Tavistock’s Experiment with Puberty Blockers. In: Moore, M. & Brunskell-Evans, H. (eds.). Inventing Transgender Children and Young People. Cambridge Scholars Publishing. [Link] ↩︎
- Baker, K.E., Wilson, L.M., Sharma, R., Dukhanin, V., McArthur, K. & Robinson, K.A. (2021) Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. Journal of the Endocrine Society 5 (4). [Link] ↩︎
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The profile of people seeking transition has shifted drastically, from overwhelmingly middle-aged males to predominantly adolescent females
A 2017 paper1 notes that “in adolescents, there has been a recent inversion in the sex ratio from one favouring birth-assigned males to one favouring birth-assigned females.” By contrast, over 90% of transsexual adults in the 1960s were male2.
In fact, there was hardly any scientific literature before 2012 on girls ages 11 to 21 ever having developed gender dysphoria at all. Yet of the young people described in Lisa Littman’s 2018 seminal paper on young people3, 82.8% were female.
The data for the UK’s Gender Identity Development Service4 show that 138 children were referred in 2011, and most of those children were boys. By 2021, however, a complete sex ratio reversal had occurred, and the clinic saw 2383 children that year, with almost 70% being female.
A 2017 article by Lisa Marchiano5 collated data from different clinics around the world and found international evidence for this shift in distribution.
- Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health 14 (5): 404-411. [Link] ↩︎
- Barrett, J. (2015). Written evidence submitted by British Association of Gender Identity Specialists to the Transgender Equality Inquiry. data.parliament.uk [Link] ↩︎
- Littman, L. (2018). Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLOS ONE, 13 (8). [Link] ↩︎
- Gender Identity Development Service (2021). Referrals to GIDS, financial years 2010-11 to 2020-21. [Link] ↩︎
- Marchiano, L. (2017). Outbreak: On Transgender Teens and Psychic Epidemics. Psychological Perspectives 60 (3): 345-366. [Link] ↩︎
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There has been a roughly twenty-fold rise in the number of people seeking transition, with teenagers hugely over-represented
A 2017 paper1 reports that “the prevalence of a self-reported transgender identity in children, adolescents and adults ranges from 0.5 to 1.3%, markedly higher than prevalence rates based on clinic-referred samples of adults.”
This is reflected in data from gender clinics. The UK’s Gender Identity Development Service reported2 a twenty-fold increase in referrals over the course of the last decade:
This surge was primarily driven by adolescents, with 15 being the most common age of referral:
Similarly, a Dutch gender identity clinic reported3 a twenty-fold increase, albeit over a longer time span: from 34 in 1980 to 686 in 2015:
New Zealand4, Finland5 and Canada6 have recorded similar dramatic exponential increases.
- Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health 14 (5): 404-411. [Link] ↩︎
- Gender Identity Development Service (2021). Referrals to GIDS, financial years 2010-11 to 2020-21. [Link] ↩︎
- Wiepjes, C.M., Nota, N.M., de Blok, C.J.M., Klaver, M., de Vries, A.L.C., Wensing-Kruger, S.A., de Jongh, R.T., Bouman, M.B., Steensma, T.D., Cohen-Kettenis, P., Gooren, L.J.G., Kreukels, B.P.C. & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Journal of Sexual Medicine 15 (4). [Link] ↩︎
- Delahunt, J.W., Denison, H.J., Sim, D.A., Bullock, J.J. & Krebs, J.D. (2018). Increasing rates of people identifying as transgender presenting to Endocrine Services in the Wellington region. N Z Med J 131: 33-42. [Link] ↩︎
- Kaltiala-Heino, R., Sumia, M., Työläjärvi, M. & Lindberg, N. (2015). Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health 9 (1). [Link] ↩︎
- Aitken, M., Steensma, T.D., Blanchard, R., VanderLaan, D.P., Wood, H., Fuentes, A., Spegg, C., Wasserman, L., Ames, M., Fitzsimmons, C.L., Leef, J.H., Lishak, V., Reim, E., Takagi, A., Vinik, J., Wreford, J., Cohen-Kettenis, P.T., de Vries, A.L., Kreukels, B.P. & Zucker, K.J. (2015). Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med 12 (3): 756-63. [Link] ↩︎
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Puberty blockers are more than a ‘pause button’: roughly 98% of children who take them go on to take cross-sex hormones
A 2021 study from the UK1 found that only 1 out of 44 children placed on puberty blockers did not continue to take cross-sex hormones.
Similarly, a Dutch study2 reported that only 1.9% of adolescents who started puberty suppression treatment abandoned this course and did not take cross-sex hormones.
In fact, in a different Dutch study3, “[n]o adolescent withdrew from puberty suppression, and all started cross‐sex hormone treatment, the first step of actual gender reassignment.”
Puberty blockers are drugs which change young bodies in ways we have yet to understand, and may be permanent. This is an experimental treatment program: puberty blockers have never been licensed to treat children with gender dysphoria, in any country.
- Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS ONE 16 (2). [Link] ↩︎
- Wiepjes, C.M., Nota, N.M., de Blok, C.J.M., Klaver, M., de Vries, A.L.C., Wensing-Kruger, S.A., de Jongh, R.T., Bouman, M.B., Steensma, T.D., Cohen-Kettenis, P., Gooren, L.J.G., Kreukels, B.P.C. & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Journal of Sexual Medicine 15 (4). [Link] ↩︎
- de Vries, A.L.C., Steensma, T.D., Doreleijers, T.A. & Cohen-Kettenis, P.T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 8 (8): 2276-83. [Link] ↩︎