Category: Medical transition
-
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/ ↩︎
-
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. ↩︎
-
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. ↩︎
-
Time until treatment regret emerges may be eight years or more.
An analysis1 showed that the median time to surgical regret may be as high as eight years. For cross-sex hormone treatment, the time to regret may be almost eleven years (130 months). However, the analysis points out that the lack of thorough follow up in much of the research in this field, and the lack of detailed research into the detransitioner/desister population, mean that accurate figures are very hard to discern.
- Cohn, J. The Detransition Rate Is Unknown. Archives of Sexual Behaviour 52, 1937–1952 (2023). https://doi.org/10.1007/s10508-023-02623-5 ↩︎
-
Quality Of Life scores start to decline around one year after “gender-affirming” surgery. After five years, these scores are below pre-surgery levels.
A systematic review and meta-analysis1 of studies on the Quality Of Life (QoL) of transgender patients showed that in every domain, these patients tended to have poor QoL compared to the general population. Some patients showed an increase in QoL in some domains, but this peaked after about a year. After five years, these scores were below pre-transition levels.
- Nobili, A., Glazebrook, C. & Arcelus, J. Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis. Rev Endocr Metab Disord 19, 199–220 (2018). https://doi.org/10.1007/s11154-018-9459-y ↩︎
-
36% of patients at Amsterdam gender clinic were lost to follow up.
In a study of all patients at a clinic treating 95% of all trans-identified people in the Netherlands1, 36% of all patients were lost to follow up. This may make reported rates of regret or detransition highly unreliable2. Rates of “regret” in the study itself may be compromised by a definition of “true regret” marked by beginning hormone therapy reflecting the patient’s sex (e.g. testosterone therapy for detransitioning “trans women” or estrogen therapy for detransitioning “trans men.”) The study also notes that some of those experiencing “true regret” had thought that transition would be a “solution” for their homosexuality. Regret was expressed between 46 and 271 months after beginning cross-sex hormone treatment. This may suggest there is a long tail of such regret still to come, even from those who began treatment more than twenty years ago.
- Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, de Jongh RT, Bouman MB, Steensma TD, Cohen-Kettenis P, Gooren LJG, Kreukels BPC, den Heijer M. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018 Apr;15(4):582-590. doi: 10.1016/j.jsxm.2018.01.016. Epub 2018 Feb 17. PMID: 29463477 ↩︎
- https://catalogofbias.org/biases/attrition-bias/ ↩︎
-
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 ↩︎
-
Males on feminizing hormones face over double the risk of kidney stones.
A 2025 analysis1 of NIH medical records found that 10.3% of males on feminizing hormone therapy developed kidney stones, compared to 4.8% of those not on hormones. The risk was especially elevated for those on both estrogen and antiandrogens, with odds more than 2.5 times higher.
- Frangopoulos, E., Savin, Z., Gupta, K., Durbhakula, V., Gallante, B., Atallah, W. M., & Gupta, M. (2025). Increased Risk of Kidney Stones in Transgender Women and Gender-Diverse Adults on Gender-Affirming Hormone Therapy: Insights from a Large Database Study. Journal of Endourology. ↩︎
-
One in five vaginoplasty patients develop genital prolapse.
A 2025 Swiss follow‑up study1 (mean 27.5 years post‑surgery) found prolapse rates highest among those with peritoneal vaginoplasty (83%), followed by penile‑inversion techniques (17%) and intestinal vaginoplasty (14%). Surgical repairs often reduced symptoms but highlight long‑term complications rarely discussed before transition.
- Osswald, R., Villiger, A. S., Ruggeri, G., Hoehn, D., Mueller, M., & Kuhn, A. (2025). Twenty-Seven Years After Sex Reassignment Surgery in Female Transgender Patients: Is Prolapse of the Neovagina an Issue?. International Urogynecology Journal, 1-7. [Link] ↩︎
-
“Gender-affirming” hormone therapy increases BMI.
A 2025 systematic review and meta-analysis1 of 29 studies (28 included in meta-analysis) involving 2,674 individuals found that “gender-affirming” hormone therapy led to statistically significant body mass index (BMI) increases. The mean age across studies ranged from 16 to 56 years, and no prior puberty suppression was reported before the initiation of GAHT. The researchers excluded studies with adolescent samples or with pubertal suppression prior to hormone therapy. Natal males receiving feminizing hormones experienced an average BMI increase of 0.55 kg/m², while natal females receiving masculinizing testosterone showed a larger average increase of 0.92 kg/m². The study authors noted these represent modest weight gains with moderate certainty of evidence, though they concluded the changes reflect expected hormonal effects rather than pathological outcomes.
- Gois, Í., Rodrigues, F. B., Pereira, M., Dias-da-Silva, M. R., & Gomes, S. M. (2025). Body mass index and body composition changes in transgender people undergoing gender-affirming hormone therapy: a systematic review and meta-analysis. Reviews in Endocrine and Metabolic Disorders, 1-17. [Link] ↩︎
-
Trans-identified adolescents are prescribed psychotropic medications more than twice as often as their siblings, with rates increasing after medical transition.
A 2021 study in the Journal of Sexual Medicine1 found that trans-identified adolescents in the US military healthcare system were prescribed psychotropic medications (such as antidepressants, sleep aids, antipsychotics, and mood stabilizers) at more than double the rate of their siblings (IRR = 2.57), with prescriptions increasing after “gender-affirming pharmaceutical initiation” (IRR = 1.67). The study compared mental health diagnoses, service use, and medication patterns before and after this medical transition step.
- Hisle-Gorman, E., Schvey, N. A., Adirim, T. A., Rayne, A. K., Susi, A., Roberts, T. A., & Klein, D. A. (2021). Mental healthcare utilization of transgender youth before and after affirming treatment. The Journal of Sexual Medicine, 18(8), 1444-1454. [Link] ↩︎
-
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] ↩︎
-
“Gender-affirming” surgery is associated with increased risk of depression, anxiety, suicidal ideation, and substance use disorders.
A 2025 U.S. national database study1 examined over 107,000 adults diagnosed with gender dysphoria to compare those who did and did not undergo “gender-affirming” surgery. Using matched cohorts controlling for age, race, and ethnicity, the study found significantly higher risks of depression, anxiety, suicidal ideation, and substance use disorders within two years after surgery.
For males who had surgery, depression was 25.4% vs. 11.5% without surgery (RR 2.20) and anxiety 12.8% vs. 2.6% (RR 4.88). Females also showed increased rates: depression 22.9% vs. 14.6% (RR 1.56) and anxiety 10.5% vs. 7.1% (RR 1.48). Those undergoing feminizing procedures had particularly elevated risk for depression (RR 1.78) and substance use disorders (RR 1.28).
- Lewis, J. E., Patterson, A. R., Effirim, M. A., Patel, M. M., Lim, S. E., Cuello, V. A., … & Lee, W. C. (2025). Examining gender-specific mental health risks after gender-affirming surgery: a national database study. The Journal of Sexual Medicine, 22(4), 645-651. [Link] ↩︎
-
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]
↩︎
- 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]
-
Genital surgery is associated with high rates of pelvic floor and sexual dysfunction.
A 2025 systematic review and meta-analysis1 examined 25 studies on pelvic floor outcomes after genital “gender-affirming” surgery. The findings show a high prevalence of complications among both male and female patients:
Type of Dysfunction Males (vaginoplasty) Females (hysterectomy & phalloplasty) Pelvic organ prolapse 1–7.5% 3.8% Urinary incontinence up to 15% up to 50% Urinary irritative symptoms up to 20% up to 37% Sexual dysfunction 25–75% 54% - Dominoni, M., Scatigno, A. L., Pasquali, M. F., Bergante, C., Gariboldi, F., & Gardella, B. (2025). Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: a systematic review and meta-analysis. The Journal of Sexual Medicine, 22(1), 184-195. [Link] ↩︎
-
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] ↩︎
-
Puberty blockers potentially have a negative impact on neuropsychological functioning
A 2024 review by Sallie Baxendale1 extensively examined the neuropsychological impacts of puberty blockers. The review indicated that animal studies showed a non-reversible negative impact on cognitive and behavioral functions. In human studies, the evidence suggested detrimental effects on IQ among those treated with puberty blockers for precocious puberty. Specifically, one study documented an average decrease in full-scale IQ of 7 points, including a case where an individual’s IQ fell by 15 points from 138 to 123 after treatment. Another case study involving a gender dysphoric young person reported a drop of 9 points in global (overall) IQ and 15 points in working memory during the course of treatment with puberty blockers.
- Baxendale, S. (2024). The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatrica, 113(7), 1156-1167. [Link] ↩︎
-
People who have undergone cross-sex surgery are over 19 times more likely to die by suicide than the general population
Dhejne et al. (2011)1 conducted the longest follow-up study to date on the outcomes of “sex reassignment surgery”, covering a period of 30 years (1973-2003) and involving 324 individuals in Sweden. The study compared these individuals to matched controls based on birth year and sex, revealing that those who had undergone surgery exhibited a significantly increased suicide risk, with rates nearly 19.1 times higher than their matched controls.
- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one, 6(2), e16885. [Link] ↩︎
-
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] ↩︎
-
People who have undergone cross-sex surgery exhibit a significantly higher suicide risk
Dhejne et al. (2011)1 conducted the longest follow-up study to date on the outcomes of “sex reassignment surgery”, covering a period of 30 years (1973-2003) and involving 324 individuals in Sweden. The study compared these individuals to matched controls based on birth year and sex, revealing that those who had undergone surgery exhibited a significantly increased suicide risk, with rates nearly 19.1 times higher than their matched controls.
In the US, a 2024 study by Straub et al.2 analyzed the psychiatric risks of those who’ve undergone “gender-affirmation surgery” using a large patient dataset. This study compared individuals who had undergone the surgery to two control groups: one consisting of adults who had emergency department visits without any surgery and another comprising individuals who underwent either a tubal ligation or vasectomy. The findings indicated that those who had “gender-affirmation surgery” faced a 12.12-fold increased risk of attempting suicide compared to the emergency visit control group, and a 4.71-fold higher risk compared to the tubal ligation/vasectomy control group.
- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one, 6(2), e16885. [Link] ↩︎
- Straub, J. J., Paul, K. K., Bothwell, L. G., Deshazo, S. J., Golovko, G., Miller, M. S., & Jehle, D. V. (2024). Risk of suicide and self-harm following gender-affirmation surgery. Cureus, 16(4). [Link] ↩︎