Category: Females
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NHS gender clinics do not meet quality assurance standards.
An operational and delivery review1 of adult gender clinics in England found that clinics lacked patient outcome data, had limited data reporting of inconsistent quality, and had minimal clinical audit. These failings put the clinics outside standard NHS quality assurance expectations.
These clinics also showed no signs of responding to the changing demographics of their referrals. Clinics made little effort to respond to the needs of this changing cohort, which was younger and more female than had previously been the case.
Some clinics reportedly carried out little or no knowledge-sharing or quality improvement work. Senior clinical leadership also steered some clinicians away from appropriate clinical curiosity, limiting opportunities to improve patient outcomes. In addition, many clinics were not well overseen by their local trust boards, nor by NHS England.
- Levy D, Operational and delivery review of NHS adult gender dysphoria clinics in England. https://www.england.nhs.uk/publication/operational-and-delivery-review-of-nhs-adult-gender-dysphoria-clinics-in-england/ ↩︎
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All-cause mortality is higher for women taking testosterone than for women in general.
A retrospective cohort study1 of patients at an Amsterdam gender clinic found that all-cause mortality increased for females receiving testosterone and continued to increase over time. Women taking testosterone had an overall Standard Mortality Ratio (SMR) of 1.8 compared to women in general. Deaths from non-natural causes were especially high.
- de Blok CJ, Wiepjes CM, van Velzen DM, Staphorsius AS, Nota NM, Gooren LJ, Kreukels BP, den Heijer M. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes and Endocrinology. 2021 Oct;9(10):663-670. doi: 10.1016/S2213-8587(21)00185-6. Epub 2021 Sep 2. PMID: 34481559. ↩︎
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Around one in six young people treated with cross sex hormones ceased treatment.
An exploratory study1 of adolescents and young adults in Canada and the US found that 16.8% of those receiving “gender affirming medical treatment” (puberty blockers and cross sex hormones) stopped “treatment” within around five years of declaring a “trans” or “non binary” identity.
Of those who discontinued treatment, 37.3% did so for health reasons. 32% ended treatment due to a change in gender identity. 12% were persuaded by health professionals or a partner to explore different ways of approaching their gender dysphoria.
Stopping treatment was associated with having a “non binary” identity. Both continuing and non-continuing cohorts had a mean age of 16.1 when “coming out”, but those discontinuing treatment were slightly older (22.1 vs. 20.9.)
- MacKinnon KR, Jeyabalan T, Strang JF, Delgado-Ron JA, Lam JSH, Gould WA, Cooper A, Salway T. Discontinuation of Gender-Affirming Medical Treatments: Prevalence and Associated Features in a Nonprobabilistic Sample of Transgender and Gender-Diverse Adolescents and Young Adults in Canada and the United States. Journal of Adolescent Health. 2024 Oct;75(4):569-577. doi: 10.1016/j.jadohealth.2024.05.015. Epub 2024 Jun 28. PMID: 38944803. ↩︎
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Bone mineral density that declines during puberty blockade may not fully recover with cross-sex hormone treatment.
A cohort study1 of trans-identified people who had received puberty blockers and long-term cross sex hormones found that bone mineral density z-scores (which compare the patient with age- and sex-typical values) fell during puberty blockade, and did not fully recover following over a decade of cross-sex hormone treatment. This was especially the case for the lumbar spine of males receiving estrogen.
It is also notable that, of the original 143 eligible participants, only 75 completed this research. Of those who left the cohort, 6 (4%) had discontinued cross-sex hormone treatment and 27 (19%) could not be reached. These figures are consistent with high loss to follow up in other studies of so-called “gender-affirming care.”
- van der Loos MATC, Vlot MC, Klink DT, Hannema SE, den Heijer M, Wiepjes CM. Bone Mineral Density in Transgender Adolescents Treated With Puberty Suppression and Subsequent Gender-Affirming Hormones. JAMA Pediatrics. 2023 Dec 1;177(12):1332-1341. doi: 10.1001/jamapediatrics.2023.4588. PMID: 37902760; PMCID: PMC10616766. ↩︎
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Depression symptoms got worse in children taking puberty blockers.
In a study1 of 94 children with gender dysphoria, aged 8-16 and beginning to take puberty blockers, depression symptoms were more likely to get worse than to improve over two years of treatment. Scores on the Beck Depression Inventory (BDI-Y) went from 72% average, 10% mildly elevated, 10% moderately elevated, and 8% severely elevated at baseline to 75% average, 7% mildly elevated, 14% moderately elevated, and 9% severely elevated after 24 months.
This study was conducted from 2016 to 2021 by Dr. Johanna Olson-Kennedy. In 2024, the New York Times reported2 Dr. Olson-Kennedy saying that publication of this research had been delayed because she feared that research showing that puberty blockers did not improve patients’ mental health would be “weaponized” against the use of puberty blockers by opponents of the practice. The report appeared as a pre-print, not peer-reviewed, in May 2025.
- Johanna Olson-Kennedy, Liyuan Wang, Carolyn F. Wong, Diane Chen, Diane Ehrensaft, Marco A. Hidalgo, Amy C. Tishelman, Yee-Ming Chan, Robert Garofalo, Asa E. Radix, Stephen M. Rosenthal, Emotional Health of Transgender Youth 24 Months After Initiating Gender-Affirming Hormone Therapy, Journal of Adolescent Health, Volume 77, Issue 1, 2025, Pages 41-50, ISSN 1054-139X, https://doi.org/10.1016/j.jadohealth.2024.11.014. ↩︎
- https://www.nytimes.com/2024/10/23/science/puberty-blockers-olson-kennedy.html
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Women taking GnRH agonists for endometriosis experienced memory problems during treatment.
A study1 of women taking GnRH agonists (a/k/a “puberty blockers”) to treat endometriosis found that 31% had “mild” memory problems, 25% had “moderate” problems, and 19% had “marked” problems. Problems were mainly with prospective and short-term memory.
- Christopher Newton, Dianne Slota, Albert A. Yuzpe, Ian S. Tummon, Memory complaints associated with the use of gonadotropin-releasing hormone agonists: a preliminary study, Fertility and Sterility, Volume 65, Issue 6, 1996. ISSN 0015-0282. https://doi.org/10.1016/S0015-0282(16)58351-4. ↩︎
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The IQ of girls given puberty blockers for precocious puberty fell by eight points.
A study1 of 15 girls treated with puberty blockers for central precocious puberty showed that IQ fell by around eight points. The average fell from 102 (55th percentile) to 94 (34th percentile). Two patients were held back a year at school.
In another study2 of 30 children experiencing early puberty and treated with puberty blockers, IQ fell by around seven points.
- Wojniusz S, Callens N, Sütterlin S, Andersson S, De Schepper J, Gies I, Vanbesien J, De Waele K, Van Aken S, Craen M, Vögele C, Cools M, Haraldsen IR. Cognitive, Emotional, and Psychosocial Functioning of Girls Treated with Pharmacological Puberty Blockage for Idiopathic Central Precocious Puberty. Frontiers in Psychology. 2016 Jul 12;7:1053. doi: 10.3389/fpsyg.2016.01053. PMID: 27462292; PMCID: PMC4940404. ↩︎
- Mul D, Versluis-den Bieman HJ, Slijper FM, Oostdijk W, Waelkens JJ, Drop SL. Psychological assessments before and after treatment of early puberty in adopted children. Acta Paediatrica. 2001 Sep;90(9):965-71. doi: 10.1080/080352501316978011. PMID: 11683207. ↩︎
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94% of females taking testosterone experience pelvic floor dysfunction.
In a study1 of 68 women taking testosterone, 94.1% had some form of pelvic floor dysfunction. 86.7% had urinary symptoms. Other problems included storage symptoms (69.1%), sexual dysfunction (52.9%), anorectal symptoms (45.6%), and flatal incontinence (39.7%.)
- da Silva LMB, Freire SND, Moretti E, Barbosa L. Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study. International Urogynecology Journal. 2024 May;35(5):1077-1084. doi: 10.1007/s00192-024-05779-3. Epub 2024 Apr 25. PMID: 38662108. ↩︎
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Exogenous testosterone in females is correlated with symptoms of glaucoma.
A prospective study1 comparing twenty females taking “gender-affirming” testosterone with twenty other women and twenty men found that exogenous testosterone was associated with higher intra-ocular pressure, reduced ocular blood flow, and increased thickness of the retinal nerve fiber layer, ganglion cell complex, and macula.
- Alpogan O, Donmez EE, Balık AÖ, Vural F, Kaplan G. Effects of testosterone on intraocular pressure, thicknesses of retinal nerve fiber layer, ganglion cell complex, macula and on ocular blood flow in female-to-male transgender persons. International Ophthalmology. 2021 Nov;41(11):3651-3661. doi: 10.1007/s10792-021-01921-y. Epub 2021 Jul 8. PMID: 34240322. ↩︎
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There may be a causal link between exogenous testosterone and idiopathic intracranial hypertension (IIH.)
In a study1 of a series of cases of females taking “gender-affirming” testosterone, a plausible causal relationship was suggested between the exogenous testosterone and the precipitation of symptoms of idiopathic intracranial hypertension (IIH). Onset of IIH was between ten weeks and ten years after beginning testosterone treatment.
- Gutkind NE, Tse DT, Johnson TE, Tse BC. Idiopathic Intracranial Hypertension in Female-to-Male Transgender Patients on Exogenous Testosterone Therapy. Ophthalmic Plastic and Reconstructive Surgery. 2023 Sep-Oct 01;39(5):449-453. doi: 10.1097/IOP.0000000000002344. Epub 2023 Feb 21. PMID: 36804335; PMCID: PMC10440365. ↩︎
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Females taking testosterone may be at increased risk of intracranial hypertension.
A case study1 of idiopathic intracranial hypertension (IIH) in a woman taking “gender-affirming” testosterone suggests that there may be a causal link between elevated testosterone and the onset and progression of IIH.
- Hornby C, Mollan SP, Mitchell J, Markey KA, Yangou A, Wright BLC, O’Reilly MW, Sinclair AJ. What Do Transgender Patients Teach Us About Idiopathic Intracranial Hypertension? Neuroophthalmology. 2017 May 10;41(6):326-329. doi: 10.1080/01658107.2017.1316744. PMID: 29238388; PMCID: PMC5706971. ↩︎
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Autistic traits are more common in trans-identified girls than trans-identified boys.
A cohort study of Australian children with trans identities1 found that 74.5% of the autistic group were female, compared to 64% of the non-autistic group. Females formed a significant majority of both groups.
- A comparison of gender diversity in transgender young people with and without autistic traits from the Trans 20 cohort study
Tollit, Michelle A. et al.
The Lancet Regional Health – Western Pacific, Volume 47, 101084 ↩︎
- A comparison of gender diversity in transgender young people with and without autistic traits from the Trans 20 cohort study
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Rates of gender-affirming surgeries in the US tripled from 2016-2019.
A cohort study1 of data from the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample showed that 48019 patients in the US received some kind of “gender-affirming” surgery between 2016 and 2020. Numbers peaked at 13011 in 2019 then fell slightly to 12818 in 2020. The study’s authors attribute this decline to the impact of the COVID-19 pandemic though, meaning the historical peak may not have been reached by then. 7.7% of all patients (3678 of the total) were aged 12-18 at the time of their surgery. 405 of these surgeries on minors (2.4% of the whole study) were genital surgeries. More than half (52.3%, or 25099 patients) were aged 19-30.
- Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Network Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348 ↩︎
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Testosterone induces distinct cellular changes in female reproductive organs—including prostate-like tissue in the vagina, uterine atrophy, cyst-filled ovaries, and male-pattern cells in the cervix.
A 2025 study1 retrospectively reviewed histopathology slides from 20 trans-identifying females (ages 16–35) who underwent “gender-affirming” gynecologic surgery following 4–63 months of testosterone therapy (mean duration 21.7 ± 17.8 months).
Key findings included:
- 100% showed NKX3.1-positive basal keratinocytes in the cervix (a marker normally found in male prostate tissue)
- 55% and 60% of cervical samples showed transitional and prostatic-type metaplasia (cell changes resembling male urethral and prostate tissue)
- 100% and 50% of vaginal samples showed the same respective patterns
- 75% had an inactive uterine lining (endometrium)
- 55% showed ciliated cell metaplasia (development of hair-like cells typically not present)
- 65% had stromal expansion and decidua-like change (tissue patterns resembling early pregnancy)
- 70% had numerous cystic follicles in the ovaries, and 60% showed signs of follicular maturation
- One patient had ovarian endometriosis; one had a mucinous cyst adenofibroma
- Fallopian tubes had paratubal mesonephric remnants, but no hypertrophy (enlargement)
A comparison group of 25 benign hysterectomy samples from females of reproductive age showed no transitional or prostatic-type metaplasia, and only 2 cases (8%) had focal NKX3.1 positivity.
- Bakshi, N., Nanda, B., Rao, S., Badwal, S., & Dhawan, S. (2025). Spectrum of Histopathologic Findings in Transgender Men Undergoing Gender-Affirming Gynecologic Surgery Following Preoperative Androgen Therapy: A Tertiary Care Center Study. International journal of surgical pathology, 10668969251363990. Advance online publication. https://doi.org/10.1177/10668969251363990 ↩︎
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Around 25–50% of transmen and 5–10% of transwomen have had genital surgery.
Based on a 2019 review, genital surgery1 as part of medical transition is generally less common than chest surgery, with reported rates of 25–50% for transmen (natal females) and 5–10% for transwomen (natal males). These estimates come from a range of surveys and clinical reports.
- Nolan, I. T., Kuhner, C. J., & Dy, G. W. (2019). Demographic and temporal trends in transgender identities and gender confirming surgery. Translational andrology and urology, 8(3), 184. [Link] ↩︎
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Testosterone use in females triggers biological signs of kidney stress and injury within just three months.
In a 2025 study in the Journal of Clinical Investigation1, females taking testosterone for gender transition showed biological changes consistent with subclinical kidney stress and tubular injury after three months—including a 134% increase in a urinary marker linked to kidney inflammation (YKL-40) and an 8% rise in an inflammatory blood protein (TNF receptor-1). Although overall kidney filtration remained unchanged, testosterone negatively affected kidney-protective proteins and activated pathways tied to inflammation, tissue remodeling, and fibrosis. The researchers called for long-term studies in larger populations to assess potential lasting effects.
- van Eeghen, S. A., Pyle, L., Narongkiatikhun, P., Choi, Y. J., Obeid, W., Parikh, C. R., … & Nokoff, N. J. (2025). Unveiling mechanisms underlying kidney function changes during sex hormone therapy. The Journal of Clinical Investigation. [Link]
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- van Eeghen, S. A., Pyle, L., Narongkiatikhun, P., Choi, Y. J., Obeid, W., Parikh, C. R., … & Nokoff, N. J. (2025). Unveiling mechanisms underlying kidney function changes during sex hormone therapy. The Journal of Clinical Investigation. [Link]
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Trans-identified females report higher rates of sexual assault than their male counterparts.
A study by Abern et al.1 surveyed 996 trans-identified adults and found that 50% of females reported experiencing sexual assault, compared to 37% of males.
- Abern, L., Diego, D., Krempasky, C., Cook, J., & Maguire, K. (2023). Prevalence of sexual assault in a cohort of transgender and gender diverse individuals. Journal of general internal medicine, 38(5), 1331-1333. [Link] ↩︎
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Polycystic ovary syndrome (PCOS) is more prevalent in females seeking medical transition.
A 2025 study1 from Argentina found that 26.6% of female adults presenting for “gender-affirming hormone therapy” had polycystic ovary syndrome (PCOS) prior to starting any hormonal treatment. PCOS is a hormonal disorder characterized by irregular periods, excess male hormone levels, and cysts on the ovaries. This rate is 2-3 times higher than the 8-13% prevalence in the general female population.2
A 2024 study3 from the Cleveland Clinic similarly found 23.8% of adolescent females presenting for “gender-affirming hormone therapy” had PCOS, with higher male hormone levels, higher BMIs, and increased rates of dyslipidemia than those without PCOS.
- Calvar, C. E., Di Noto, M., Lema Villacis, M., Blanco Hirota, N., & Anticona Sayán, M. I. (2025). Prevalencia, distribución fenotípica y riesgo cardiometabólico del síndrome de ovario poliquístico en población transgénero [Prevalence, phenotype distribution and cardiometabolic risk of polycystic ovarian syndrome in transgender population]. Medicina, 85(1), 31–38. [Link] ↩︎
- March, W. A., Moore, V. M., Willson, K. J., Phillips, D. I., Norman, R. J., & Davies, M. J. (2010). The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Human reproduction, 25(2), 544-551. [Link]
↩︎ - Rangi, S. K., Rehmer, J., & Ferrando, C. A. (2024). Prevalence of polycystic ovarian syndrome in young and adolescent transmasculine patients presenting for gender-affirming care. Journal of Pediatric and Adolescent Gynecology, 37(1), 51-55. [Link] ↩︎
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Long-term testosterone use in females may induce early menopause, leading to pelvic dysfunction, increased mortality risk and many other challenges
A 2024 study by da Silva et al1. found that 94.1% of 68 trans-identified females using testosterone experienced pelvic dysfunctions typically seen in postmenopausal women, including urinary (86.7%), sexual (52.9%), and bowel (45.6%) problems. These symptoms appeared as early as age 18, with an average onset age of 28.
This early onset of menopausal-like symptoms is particularly concerning given findings from another 2024 study by Haapakoski et al.2, which demonstrated increased mortality risks associated with early menopause. The study found that women experiencing early menopause (n=5,800) were twice as likely to die from heart disease and four times more likely to die from cancer compared to those with typical menopause onset (n=23,000).
Testosterone use may induce early menopause by inhibiting ovarian function3 and decreasing estrogen production in the body4.
- da Silva, L. M. B., Freire, S. N. D., Moretti, E., & Barbosa, L. (2024). Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study. International Urogynecology Journal, 1-8. [Link] ↩︎
- Haapakoski, H., Silven, H., Pesonen, P., Savukoski, S., & Niinimaki, M. (2024, May). Mortality among women with POI, nationwide register based case-control study. In Endocrine Abstracts (Vol. 99). Bioscientifica. [Link] ↩︎
- Bailie, E., Maidarti, M., Hawthorn, R., Jack, S., Watson, N., Telfer, E. E., & Anderson, R. A. (2023). The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool. Reproduction and Fertility, 4(2). [Link] ↩︎
- Chan, K. J., Jolly, D., Liang, J. J., Weinand, J. D., & Safer, J. D. (2018). Estrogen levels do not rise with testosterone treatment for transgender men. Endocrine Practice, 24(4), 329-333. [Link] ↩︎
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There is a significant burden of chronic pain in trans-identified individuals, with an increased risk among those receiving cross-sex hormones
A 2024 large US clinical database study1 of 98,352 trans-identified individuals (56,470 females and 41,882 males) found significantly higher rates of chronic pain compared to the general population. Of particular concern, those receiving cross-sex hormones showed even higher risks – females on testosterone had a 20% increased hazard of chronic pain diagnosis compared to those not taking testosterone, while males on estrogen showed a 19.4% increased risk.
- Tabernacki, T., Gilbert, D., Rhodes, S., Scarberry, K., Pope, R., McNamara, M., … & Mishra, K. (2024). The burden of chronic pain in transgender and gender diverse populations: Evidence from a large US clinical database. European Journal of Pain. [Link] ↩︎