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Female to Male Gender Reassignment Surgery (FTM GRS)

Female-to-male gender reassignment surgery (FTM GRS) is a complex and irreversible genital surgery for female transsexual who is diagnosed with gender identity disorder and has a strong desire to live as male. The procedure is to remove all female genital organs including the uterus, ovaries, and vagina with the construction of male genitalia composed of the penis and scrotum.  

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Female gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.  

Apart from genital surgery, the patient would seek other procedures to allow them to live as males smoothly such as breast amputation, facial surgery, body surgery, etc.  

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is very complicated and only a handful of surgeons are able to perform this procedure. It is a multi-staged procedure, the first stage is the removal of the uterus, ovary, and vagina. The duration of the procedure is 2-3 hours. The second and later stages are penis and scrotum reconstruction which is at least 6 months later. There are several techniques for penile reconstruction depending on the type of tissue such as skin/fat of the forearm, skin/fat of the thigh, or adjacent tissue around the clitoris. This second stage of surgical time is between 3-5 hours. A penile prosthesis can be incorporated simultaneously or at a later stage. The scrotal prosthesis is also implanted later.  

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.  

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-7 days for each stage depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.  

Additional Information

What are the risks.

The most frequent complication of FTM GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis and fistula, unsightly scar, etc. The revision procedure is scar revision, hair transplant, or tattooing to camouflage unsightly scars.   

What is the recovery process?

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patients return to their normal lives but not having to do physical exercise during the first 2 months after surgery. The patient will have a urinary catheter continuously for several weeks to avoid a urinary fistula. If the patient has a penile prosthesis, it would need at least 6 months before sexual intimacy.  

What are the results?

With good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a male role completely and happily either on their own or with their female or male partners.  

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

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The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

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Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

9 inspiring photos to help you transition from female to male

Gender affirmation surgery can be an incredibly freeing and life-changing decision. But it’s also understandable if the thought of going under the knife makes you anxious. Like any major surgery, there are risks of complications, scarring, and infection. And depending on the kind of surgery you get, you can experience changes in sexual satisfaction and sensation in certain areas.

But for the majority of trans people who opt for  surgery , the benefits outweigh the risks and disadvantages. For one, researchers have reported that there are long-term  mental health benefits to gender affirmation surgery. Many trans people have said that the anxiety and depression they’ve had due to gender dysphoria lessens over time, and they begin to feel more comfortable, confident, and at home in their bodies. Plus, the complication rate for female to male gender affirmation surgery is relatively low at 5.8%.

If you’re still apprehensive about gender-affirming surgery and its effects on your sexual and physical health, perhaps seeing success stories from trans men who have gone through it all may help assuage your worries. So here are a few “female to male” transition photos to inspire and affirm so you can have a little bit of a preview of what to expect on your own transition.

Related:  Transgender People Are Less Healthy Than Cis People, Here’s Why

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9 Transition Photos That Prove That It Does Get Better

Before we jump into our list of inspiring images, we’d like to point out that transitioning is different for everyone. Some people may feel that gender-affirming surgery is integral to the improvement of their mental health. Others may not even see surgery and hormone therapy (HRT) as a necessary step in their transition journey. It’s totally fine either way, as long as you’re happy!

And for those who do undergo some type of procedure, remember that individual results vary. The photos included in this list are meant to inspire and affirm but are in no way the gold standard of what a trans person post-surgery is supposed to look like. In fact, there is no standard! All bodies are unique, valid, and beautiful either way.

1. Jamie Raines

Jamie Raines is an English YouTuber who often talks about his experiences as a trans man in his vlogs. Over the course of six years, Jamie documented his transition journey, taking viewers along for the ride as he experienced all the physical and psychological changes of undergoing HRT, top surgery, and metoidioplasty – a type of surgery done to create a “new penis” out of tissues taken from the clitoris.

Unlike a phalloplasty, which is a complicated procedure that involves lengthening one’s urethra and a skin graft from one’s forearm for penile construction, metoidioplasty surgery has a lower risk of urological complications and a faster healing time. Raines also underwent scrotoplasty, which is a form of lower surgery done to create a scrotum.

Check out these side-by-side photos of Jamie six months after their top surgery and eight years post-op.

  View this post on Instagram   A post shared by Jamie Raines (@jammi.dodger)

2. Chella Man

Chella Man is a deaf, trans-masculine, Chinese-Jewish artist who, like Jamie, spent several years documenting his transition journey and sharing his experiences with HRT and top surgery. Chella has spoken up about having to be “his own representation” as he had a hard time finding someone else in the media who looked like him.

Last year, Chella shared a video of himself during his first top surgery consultation next to a video of himself one month post-op and eight months on testosterone. In the caption, he writes about the evident changes the procedures have done not only to his appearance but to his confidence as well.

“Today, one month post-op and 8 months on testosterone, I stand with ease, welcoming the reflection I now see,” Chella writes. “My days of dysphoria have finally passed. I am free.”

  View this post on Instagram   A post shared by Chella Man (@chellaman)

3. Aiden Mann

Aiden Mann’s journey proves that gender-affirming surgery won’t always be a walk in the park and that for some trans folk, revisions are just part of the process. Through Instagram and TikTok, Aiden has been open about his struggles with the results of his subcutaneous mastectomy (a procedure involving the removal of the tissues in one’s breasts). He’s had to undergo multiple visits to his surgeon and several revisions, particularly because of the way his nipple scars heal.

But still, Aiden persisted and seems happier than ever!

  View this post on Instagram   A post shared by Aiden Michael Mann 🏳️‍⚧️ (@aiden_m365)

4. Emmett Preciado

Emmett Preciado is a trans man and actor who has appeared on shows like Freeform’s  Good Trouble  and ABC’s  The Good Doctor . On his website bio, Emmett shares that he wrestled with his identity a lot growing up. When he hit puberty, he wore “layers and hoodies to cover his chest” because he didn’t want the girls in his class to see that he was becoming like them.

Today, you can see Emmett bare his chest proudly on Instagram. Proof positive that it does get better!

  View this post on Instagram   A post shared by Emmett Preciado (@emmettpreciado)

5. Jake Graf

While some trans men opt to get a total hysterectomy, others don’t or hold off on the surgery to have kids in the future. Such is the case of actor, writer, director, and activist Jake Graf, who had a baby with his wife via surrogacy. Jake paused his HRT for six months and had his eggs harvested at a fertility clinic.

Jake’s story is a great reminder that undergoing gender-affirming surgery and taking HRT doesn’t mean you have to give up your dreams of raising a family. Check out this precious photo of Jake with his wife Hannah and their adorable baby girl.

  View this post on Instagram   A post shared by Jake Graf (@jake_graf5)

6. Skyler Jay

Like Aiden, trans activist and community organizer Skyler Jay has been open about the issues he’s had with his health following his surgery. After Skyler underwent a double mastectomy to remove his breast tissue, he went through surgery complications, revisions, and far more months of healing than expected, but he says he wouldn’t have it any other way.

“I knew I had to go through my pain to have that top surgery”, says Skyler in a video to promote his non-profit,  Aadya Rising . “I would do it again if that’s what it meant to get me to where I’m at right now”.

Today, Skyler is living his best life. Skyler’s story and even footage of his top surgery were featured in a groundbreaking episode of Netflix’s  Queer Eye .

  View this post on Instagram   A post shared by Skyler Jay (@trans.ginger)

7. Laith Ashley

Laith is a model, actor, and activist who has been featured in major publications like  British GQ ,  Vogue France , and  Attitude UK . Growing up, Laith struggled with his sexual orientation and gender identity, as well as his family’s disapproval.

However, in an interview with  British GQ , Laith says that it was when he came across YouTube videos of trans people documenting their transition journeys that he realized “this is who I am”.

  View this post on Instagram   A post shared by Laith Ashley De La Cruz (@laith_ashley)

8. Aydian Dowling

Looking for some fitspiration? Check out the inspirational Aydian Dowling. He is a life and fitness coach and the creator of TRACE, an app that trans people can use to document their transition, take voice recordings, and create reminders for essential appointments and procedures. On his Instagram page, Aydian drops some helpful truth bombs about fitness, mental health, self-image, and self-confidence.

Oh, and did we mention he’s the first trans man to appear on a special edition cover of  Men’s Health  magazine?

  View this post on Instagram   A post shared by Aydian Dowling (a•den) (@alionsfear)

9. Leo Sheng

Like some of the others on this list, Leo Sheng’s top surgery recovery process hasn’t always been pretty. The activist, public speaker, and writer recently shared some photos from the early days of their recovery, where their scars and bruises were still very apparent. He also opened up about some of the “what if’s” they’ve had when ruminating on their journey, and whether it was all worth it, despite not getting the results he intended.

“Everyone’s bodies are different, which means everyone heals differently,” Leo writes. “I feel good about my chest today. I feel proud of it. I’m reminded to give past and present self some grace. I know that healed the best that it could – that I did the best I could”.

  View this post on Instagram   A post shared by Leo Sheng (@ileosheng)

Final Thoughts

Gender-affirming surgery doesn’t just change the way you look, it can change the entire trajectory of your life. And despite the possibility of complications, revisions, and the need for adjustments in one’s sexual expectations, most patients say they don’t regret having the surgery. And if these pictures are any indication, getting surgery is almost always worth it. Of course, as long as that’s what you really want to be happy and at ease in your body!

Related:  Drago Renteria Is The Father Of Deaf Queer Activism

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More Trans Teens Are Choosing ‘Top Surgery’

Small studies suggest that breast removal surgery improves transgender teenagers’ well-being, but data is sparse. Some state leaders oppose such procedures for minors.

By Azeen Ghorayshi

Listen to This Article

Michael, 17, arrived in the sleek white waiting room of his plastic surgeon’s office in Miami for a moment he had long anticipated: removing the bandages to see his newly flat chest.

After years of squeezing into compression undershirts to conceal his breasts, the teenager was overcome with relief that morning last December. Wearing an unbuttoned shirt, he posed for photos with his mother and the surgeon, Dr. Sidhbh Gallagher, happy to share his bare chest with the doctor’s large following on social media.

“It just felt right — like I’d never had breasts in the first place,” Michael said. “It was a ‘Yes, finally’ kind of moment.”

Michael is part of a very small but growing group of transgender adolescents who have had top surgery, or breast removal, to better align their bodies with their experience of gender. Most of these teenagers have also taken testosterone and changed their name, pronouns or clothing style.

Few groups of young people have received as much attention. Republican elected officials across the United States are seeking to ban all so-called gender-affirming care for minors, turning an intensely personal medical decision into a political maelstrom with significant consequences for transgender adolescents and their families.

Gender-related surgeries, in particular, have been thrust into the spotlight. Arizona and Alabama passed laws this year making it illegal for doctors to perform gender-related surgeries on transgender patients under 18. Conservative commentators with large followings on social media have recently targeted children’s hospitals that offer gender surgeries, leading to online harassment and bomb threats .

Genital surgeries in adolescents are exceedingly rare, surgeons said, but top surgeries are becoming more common. And while major medical groups have condemned the bans on gender-related care for adolescents, the surgeries have presented challenges for them.

Much research has shown that as adults, transgender men generally benefit from top surgery : It relieves body-related distress, increases sexual satisfaction and improves overall quality of life. A few small studies of transgender adolescents suggest similar benefits in the short term.

But some clinicians have pointed to the rising demand and the turmoil of adolescent development as reasons for doctors to slow down before offering irreversible procedures. Although medical experts believe the likelihood to be small, some patients come to regret their surgeries.

The World Professional Association for Transgender Health, an international group of gender experts who write best practices for the field, had been planning for months to set new age minimums for most gender-related surgeries, including endorsing top surgery for adolescents age 15 and up. Although the guidelines are not binding, they provide a standard for doctors across the world. But this month, the group abruptly withdrew the proposals, a shift reflecting both political pressures and a lack of consensus in the medical community.

There are no official statistics on how many minors receive top surgeries each year in the United States. The New York Times surveyed leading pediatric gender clinics across the country: Eleven clinics said they carried out a total of 203 procedures on minors in 2021, and many reported long waiting lists. Another nine clinics declined to respond, and six said that they referred patients to surgeons in private practice.

Dr. Gallagher, whose unusual embrace of platforms like TikTok has made her one of the most visible gender-affirming surgeons in the country, said she performed 13 top surgeries on minors last year, up from a handful a few years ago. One hospital, Kaiser Permanente Oakland, carried out 70 top surgeries in 2019 on teenagers age 13 to 18, up from five in 2013, according to researchers who led a recent study .

“I can’t honestly think of another field where the volume has exploded like that,” said Dr. Karen Yokoo, a retired plastic surgeon at the hospital.

Experts said that adolescent top surgeries were less frequent than cosmetic breast procedures performed on teenagers who were not transgender. Around 3,200 girls age 18 to 19 received cosmetic breast implants in 2020, according to surveys of members of the American Society of Plastic Surgeons , and another 4,700 teenagers age 13 to 19 had breast reductions. ( Surveys from other groups have shown that girls under 18 also receive implants, though the ASPS does not recommend breast augmentation for minors.)

An evolving field

In the past decade, the number of people who identify as transgender has grown significantly, especially among young Americans. Around 700,000 people under 25 identified as transgender in 2020, according to the Williams Institute , a research center at the University of California, Los Angeles, nearly double the estimate in 2017.

Gender clinics in Western Europe , Canada and the United States have reported that a majority of their adolescent patients were seeking to transition from female to male.

Because breasts are highly visible, they can make transitioning difficult and cause intense distress for these teenagers, fueling the demand for top surgeries. Small studies have shown that many transgender adolescents report significant discomfort related to their breasts, including difficulty showering, sleeping and dating. As the population of these adolescents has grown, top surgery has been offered at younger ages.

Another notable change: More nonbinary teenagers are seeking top surgeries, said Dr. Angela Goepferd, the medical director of the Gender Health Program at the Children’s Minnesota hospital, who is nonbinary. (The program does not perform operations but refers patients to independent surgeons.) These adolescents may want flatter chests but not other masculine features brought on by testosterone, like a deeper voice or facial hair.

After many months of deliberations over its new guidelines, the World Professional Association for Transgender Health initially decided to endorse top surgeries for adolescents 15 and up, part of a suite of changes that would have made gender treatments available to children at younger ages. But the organization backtracked this month, after some major medical groups it had hoped would support the new guidelines bristled at the new age minimums, according to Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of WPATH, who is transgender.

“We needed consensus,” Dr. Bowers said. “I just think we need more strength for our argument and a better political climate, frankly, in order to propose this at a younger age.”

Instead, the guidelines kept the previous recommendations, published a decade ago, allowing surgeries for minors on a case-by-case basis.

Because teenagers in most states must be 18 before they can provide medical consent, surgeons require parental consent and approval letters from mental health care providers. The two- to four-hour procedure costs anywhere from $9,000 to $17,000, depending on facility and anesthesia fees. The procedure is often not covered by insurance until patients turn 18.

As demand has grown, Dr. Gallagher, the surgeon in Miami, has built a thriving top surgery specialty. The doctor frequently posts photos, FAQs and memes on Facebook, Instagram and TikTok, proudly flouting professional mores in favor of connecting with hundreds of thousands of followers.

Her feeds often fill with photos tagged #NipRevealFriday, highlighting patients like Michael whose bandages were just removed. On her office windowsill sits a framed nameplate with one of her best-known catchphrases on TikTok: “Yeet the Teet,” slang for removing breasts.

Dr. Gallagher said she performed top surgeries on about 40 patients a month, and roughly one or two of them are under 18. Younger patients are usually at least 15, though she has operated on one 13-year-old and one 14-year-old, she said, both of whom had extreme distress about their chests.

The surgeon said that most of her patients, teenagers and adults alike, found her on TikTok. Her online presence has drawn sharp criticism from right-wing media, as well as from some parents and doctors who say she uses the platform to market to children.

“She goes to the beat of her own drum,” Dr. Bowers said. “For a lot of us, that’s troubling.”

Dr. Gallagher said she doubted she had the influence her critics ascribe to her. “Most of the time I’m just trying to deliver educational content,” she said.

‘Comfortable in my own skin’

When Michael first saw Dr. Gallagher’s TikTok page last summer, he was immediately intrigued. (Michael and others in this article asked to be identified by first or middle names because they were concerned about their privacy.) He liked the photos of her patients, observing that their scars had healed well, and liked that she seemed to be an ally of the transgender community.

Michael’s mother, Annie, had gradually come around to the idea of surgery after years of watching him suffer, she said.

Since hitting puberty at age 10, Michael said he felt a gnawing discomfort about his breasts. By the time he was 12, he wore hooded sweatshirts every day in their Miami suburb.

In eighth grade, after he had several severe panic attacks at school, Michael said he started seeing a therapist, who encouraged him to talk about his body issues. He experimented with small ways to appear more masculine, such as tucking his long curly hair into a beanie and wearing boys’ clothes.

“It was the first thing I ever did to try and make myself more comfortable in my own skin,” Michael said.

He came out to his parents as a transgender boy when he was 14. A year later, at the start of the pandemic, he started weekly testosterone injections while doing remote school. He got into strength-training and his voice dropped, a second puberty he relished but was grateful to undergo privately.

Michael started in-person school feeling “10 times happier,” he said, but his chest still tormented him. Testosterone and exercise had shrunk his breast tissue, making it easier to conceal with a binder. But the garment could restrict his breathing and give him panic attacks. He began seeing a psychiatrist, who prescribed antidepressants.

When Michael was 17, Annie said, she decided that waiting another year for surgery would put him in too much pain. Because her insurance covered the procedure only for adults, she took out a loan to help pay for it.

Michael’s psychiatrist initially wrote a letter signing off on the surgery. But he later revoked it, putting the surgery in limbo, Annie said. After Michael started a higher dose of antidepressants, the psychiatrist endorsed the surgery as planned.

Now, nine months after the operation, Michael is in his senior year of high school. He said he is focused on the parts of his life that have little to do with his gender: doing theater tech at school, seeing friends, painting and applying to college.

He also feels less pressure to prove his masculinity than before, he said. He’s growing out his hair and uses he, she and they pronouns. In June, he took his girlfriend to the prom, wearing a brown suit and a pearl necklace.

Weighing the risks

In 2018, doctors at the pediatric gender clinic at Children’s Hospital Los Angeles published a study of 136 transgender patients ages 13 to 25, half of whom had undergone top surgery. Adolescents who had not undergone the procedure reported significantly more distress because of their chests.

Roughly one-third of those who underwent surgery reported ongoing loss of nipple sensation. Only one patient expressed occasional feelings of regret, when imagining wanting to breastfeed a future child.

“There’s very few things in the world that have a zero percent regret rate. And chest surgery, clinically, I’ve experienced that,” said Dr. Johanna Olson-Kennedy, the lead author of the study and medical director of the clinic in Los Angeles, which began offering surgeries in 2019.

But the study had caveats: Most patients were surveyed less than two years after their surgeries, and nearly 30 percent could not be contacted or declined to participate.

Few researchers have looked at so-called detransitioners, people who have discontinued or reversed gender treatments. In July, a study of 28 such adults described a wide array of experiences, with some feeling intense regret and others having a more fluid gender identity.

Because so few studies have looked at detransitioning, many doctors are asking young patients and their parents to provide consent without acknowledging the unknowns, said Kinnon MacKinnon of York University in Toronto, the researcher who led the study, who is transgender.

“I know personally many, many, many trans men that have benefited and are happy with their medical transition and their top surgery. I would put myself in that category,” Dr. MacKinnon said. “But just as a researcher, I do feel like there are questions that are deserving of answers and have implications for clinical care.”

Jamie, a 24-year-old college student in Maryland, was raised as a girl and began identifying as a transgender boy in the eighth grade. After being sexually assaulted in her junior year of high school and then dropping out, she said, she started taking testosterone. Three months later, just after she turned 18, she underwent top surgery at a private practice in Massachusetts.

For the next few years, Jamie said, she thrived. Testosterone made her feel energetic, and her anxiety dissipated. She went back to school and got certified as an emergency medical technician.

But when she was 21, her father, who was dying of Alzheimer’s, no longer recognized her. She fixated on her wide hips, which she worried stood out next to her facial hair and deep voice. After a date where she had sex with a straight man, she said, she realized she had made a mistake.

“I realized I lost something about myself that I could have loved, I could have enjoyed, I could have used to feed children,” Jamie said. She said she grieved for months and contemplated suicide.

This spring, after a year of fighting her insurance company to cover the procedure, she had surgery to reconstruct her breasts. She never told her original surgeon that she had changed her mind, partly because she also blamed herself. Sometimes, she said, “I still don’t like being a woman.”

Many surgeons say that they rarely hear about patients with regret. But it’s unclear how many, like Jamie, never inform them.

Dr. Gallagher of Miami said that she follows up with patients for up to a year. “I can say this honestly: I don’t know of a single case of regret,” Dr. Gallagher said in May, adding that regret was much more common with cosmetic procedures.

But one of her former top surgery patients, Grace Lidinsky-Smith, has been vocal about her detransition on social media and in news reports.

“I slowly came to terms with the fact that it had been a mistake born out of a mental health crisis,” Ms. Lidinsky-Smith, 28, said in an interview.

She had top surgery when she was 23. About 16 months later, Ms. Lidinsky-Smith said she called and emailed her medical providers, including Dr. Gallagher’s office, to tell them she had detransitioned.

When asked about Ms. Lidinsky-Smith’s case, Dr. Gallagher amended her stance, recalling that years ago a former patient left a voice mail message expressing regret over a surgery.

“At the time, we wondered, Is it a hoax?” Dr. Gallagher said.

Chilling effect

Republican politicians in states across the country are pushing to ban all gender-affirming care for adolescents, focusing much of their rhetoric on surgeries.

In Florida, where the medical board is considering such a ban for minors, Gov. Ron DeSantis has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott has called genital surgeries in adolescents “genital mutilation.”

Dr. Bowers, the president of WPATH, said that politicians should not be involved in personal medical decisions. “They just don’t understand this care, so they just want to shut it down,” Dr. Bowers said. “That is a very dangerous precedent.”

Although most of the new state actions against gender care for minors are tied up in litigation, they have had a chilling effect.

Earlier this year, a Dallas children’s hospital shut down the only pediatric gender clinic in Texas, citing political pressure from the governor’s office. This month, a woman was arrested on charges of making a false bomb threat to Boston Children’s Hospital after it was targeted online for its pediatric gender program. Dr. Gallagher has also received threats online and said she might hire security guards for her office.

Other clinics have dropped scheduled procedures. William, 14, who has identified as a boy since he was a young child, was supposed to see a plastic surgeon in Plano, Texas, for top surgery in May. But the surgeon canceled the appointment in March because the medical center’s malpractice insurer stopped covering top surgeries for minors.

In August, William and his family flew to California, paying $10,000 more to get the procedure out of state.

Two weeks later, William started ninth grade as just another boy in school. He looks forward to swimming with his shirt off and going to class without wearing a binder.

“It’s like something was unburied,” William said. “My chest was just covering what was always there.”

Audio produced by Parin Behrooz .

An earlier version of this article misstated the timing of Jamie’s departure from high school. She dropped out after her junior year, not during it.

An earlier version of this story, relying on information from a spokesperson for the American Society of Plastic Surgeons, misstated the age range that the ASPS used for reporting data on breast implants. Its data included girls 18 to 19, not 13 to 19.

How we handle corrections

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

A Reuters Special Report

As more transgender children seek medical care, families confront many unknowns.

IN TREATMENT: Ryace Boyer, a 14-year-old high-school student, prepares to take the female hormone estrogen as part of her gender-affirming medical care. REUTERS/Megan Jelinger

USA-TRANSYOUTH/CARE

Across the United States, thousands of youths are lining up for gender-affirming care. But when families decide to take the medical route, they must make decisions about life-altering treatments that have little scientific evidence of their long-term safety and efficacy.

By CHAD TERHUNE , ROBIN RESPAUT , and MICHELLE CONLIN

Filed Oct. 6, 2022, 11 a.m. GMT

BELPRE, Ohio

On the two-hour drive back from the hospital, Danielle Boyer kept replaying the doctor’s questions in her mind. Was her then-12-year-old child, Ryace, hearing voices? Was she using illegal drugs? Had she ever been hospitalized for psychiatric treatment? Had she ever harmed herself?

Danielle was still shaken when she and Ryace arrived home in this small town nestled in a bend of the Ohio River. Dinner would have to wait. She had to talk to her husband. “They were asking us these sad, terrible questions,” she told Steve Boyer as the two sat in their garage that August 2020 evening. “Do you know kids have tried to kill themselves?”

“I had no idea,” he said.

Ryace (pronounced RYE-us) was assigned male at birth, but by the time she was 4, it was clear to her parents that she identified as a girl. She referred to herself as a girl. She wanted to dress as a girl. But her parents feared for her safety if they let her live openly as a girl in their tightly knit rural community. So they struck an uneasy compromise. At home, Ryace could be a girl, wearing makeup and dresses. At school, around town and in family photos, Ryace would remain a boy.

Ryace chafed at the restrictions. When she started middle school, she grew increasingly anxious about what puberty would bring: facial hair, an Adam’s apple, a deeper voice. That’s when Danielle sought help at Akron Children’s Hospital and its new gender clinic, where staff told her they could treat Ryace with puberty-blocking drugs and sex hormones to help her transition.

“This is what I’ve always wanted,” Ryace told her mother as they left the hospital. Afterward, the pair went on a celebratory shopping trip for girl’s clothes. Danielle was relieved. After years of struggling in isolation to do what they thought was best for Ryace, the Boyers were now getting expert help from people who understood their situation.

But the initial consultation brought troubling new questions. The doctor at the Akron clinic told Danielle and Ryace that puberty blockers could weaken Ryace’s bones. The effects on her brain development and fertility weren’t well-understood. The risk of inaction was even more alarming: Without treatment, the doctor said, Ryace would remain at increased risk of suicide.

Mention of suicide raised the stakes. “She’s been asking for how many years now to be a girl?” Danielle said to her husband as they sat talking in their garage that evening. “We just keep telling her no, and we’re crushing her. If they can help us, let’s do this.”

The United States has seen an explosion in recent years in the number of children who identify as a gender different from what they were designated at birth. Thousands of families like the Boyers are weighing profound choices in an emerging field of medicine as they pursue what is called gender-affirming care for their children.

Gender-affirming care covers a spectrum of interventions. It can entail adopting a child’s preferred name and pronouns and letting them dress in alignment with their gender identity – called social transitioning. It can incorporate therapy or other forms of psychological treatment. And, from around the start of adolescence, it can include medical interventions such as puberty blockers, hormones and, in some cases, surgery. In all of it, the aim is to support and affirm the child’s gender identity.

But families that go the medical route venture onto uncertain ground, where science has yet to catch up with practice. While the number of gender clinics treating children in the United States has grown from zero to more than 100 in the past 15 years – and waiting lists are long – strong evidence of the efficacy and possible long-term consequences of that treatment remains scant.

Puberty blockers and sex hormones do not have U.S. Food and Drug Administration (FDA) approval for children’s gender care. No clinical trials have established their safety for such off-label use. The drugs’ long-term effects on fertility and sexual function remain unclear. And in 2016, the FDA ordered makers of puberty blockers to add a warning about psychiatric problems to the drugs’ label after the agency received several reports of suicidal thoughts in children who were taking them.

More broadly, no large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning. The same lack of clarity holds true for the contentious issue of detransitioning, when a patient stops or reverses the transition process.

The National Institutes of Health, the U.S. government agency responsible for medical and public health research, told Reuters that “the evidence is limited on whether these treatments pose short- or long-term health risks for transgender and other gender-diverse adolescents.” The NIH has funded a comprehensive study to examine mental health and other outcomes for about 400 transgender youths treated at four U.S. children’s hospitals. However, long-term results are years away and may not address concerns such as fertility or cognitive development.

U.S. children ages 6 to 17 diagnosed with gender dysphoria from 2017 through 2021

U.S. children starting on puberty blockers or hormones over the five-year period

Reliable national data on how many children receive care for gender dysphoria – defined as a feeling of distress from identifying as a gender different from the one assigned at birth – have long been unavailable. To get some idea of the increasing prevalence of these cases, Reuters asked health technology company Komodo Health Inc to analyze its database of U.S. insurance claims and other medical records on about 330 million Americans. The analysis, the first of its kind, found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria in the five years to the end of 2021. More than 42,000 of those children were diagnosed just last year, up 70% from 2020.

Though smaller, the number of children receiving medical treatments like those the Akron clinic outlined for the Boyers is also growing fast. The number of children who started on puberty-blockers or hormones totaled 17,683 over the five-year period, rising from 2,394 in 2017 to 5,063 in 2021, according to the analysis. These numbers are probably a significant undercount since they don’t include children whose records did not specify a gender dysphoria diagnosis or whose treatment wasn’t covered by insurance.

Social acceptance

The surging numbers reflect in part the success of years of advocacy for transgender rights, which doctors say has made more children and their families comfortable about seeking help. Transgender children still live with discrimination, bullying and threats of violence. But as transgender identity has become more visible in popular culture, children with gender dysphoria have gained ready access on TV and social media to positive representations of young people who have received professional gender-affirming care.

Gender care for minors gained further legitimacy as medical groups endorsed the practice and began issuing treatment guidelines. Chief among them is the World Professional Association for Transgender Health, a 4,000-member organization that includes medical, legal, academic and other professionals from around the world. Over the past decade, its guidelines have been echoed by the likes of the American Academy of Pediatrics and the Endocrine Society, which represents specialists in hormones.

In its latest Standards of Care, released in September, WPATH notes the paucity of research supporting the long-term effectiveness of medical treatment for adolescents with gender dysphoria. As a result, the guidelines say, “a systematic review regarding outcomes of treatment in adolescents is not possible.” The Endocrine Society, in its own guidelines, acknowledges the “low” or “very low” certainty of evidence supporting its recommendations.

The federal government eased the path to treatment in 2016, when the administration of President Barack Obama prohibited health insurers and medical providers from limiting care because of a person’s gender identity. That prompted an expansion of public and private insurance coverage for gender-affirming care, including for children, which can cost tens of thousands of dollars a year for puberty blockers alone.

Today, more than half of states pay for gender-transition treatment through Medicaid, the government health insurance program for millions of low-income families. Nine states exclude youth gender care from Medicaid coverage. Florida, in its Medicaid prohibition, says treatments for gender dysphoria “do not meet the definition of medical necessity.”

That disparity among states is symptomatic of how gender-affirming care has become a flashpoint in the nation’s highly polarized politics.

Many conservatives decry it as a form of child abuse. “You don’t disfigure 10, 12, 13-year-old kids based on gender dysphoria,” Florida Governor Ron DeSantis, a Republican, said at an August news conference, just days before his state banned Medicaid coverage of gender care for children. Alabama, Arkansas and Texas have enacted laws or policies to broadly limit children’s access to care, all of them since blocked by courts. In more than a dozen other states, including Ohio, where the Boyers live, legislators have introduced bills that would ban care or penalize providers for treating children.

“Gender-affirming care for transgender youth is essential and can be life-saving.” Dr Rachel Levine, assistant secretary at the U.S. Department of Health and Human Services

At the same time, at least a dozen states, including New York, California and Massachusetts, have aligned with transgender advocates and many medical providers by ensuring that children are guaranteed access to care. And in July, the Biden administration proposed an expansion of the Obama-era protections.

“Gender-affirming care for transgender youth is essential and can be life-saving,” Dr Rachel Levine, an assistant secretary at the U.S. Department of Health and Human Services, said in an interview with Reuters.

Levine, a pediatrician and a transgender woman, drew outcry from conservative opponents of children’s gender care and some medical professionals earlier this year when she told National Public Radio: “There is no argument among medical professionals – pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, et cetera – about the value and the importance of gender-affirming care.”

Levine was right, insofar as healthcare providers generally agree that anyone with gender dysphoria has a right to supportive care, whether that entails social transition, or counseling and therapy, or medical interventions. But her statement glossed over deep fissures that have opened within the gender-care community over the way treatment has evolved in the United States as new patients pour into clinics.

A growing number of gender-care professionals say that in the rush to meet surging demand, too many of their peers are pushing too many families to pursue treatment for their children before they undergo the comprehensive assessments recommended in professional guidelines.

Such assessments are crucial, these medical professionals say, because as the number of pediatric patients has surged, so has the number of those whose main source of distress may not be persistent gender dysphoria. Some could be gender fluid, with a gender identity that changes over time. Some may have mental health problems that complicate their cases. For these children, some practitioners say, medical treatment may pose unnecessary risks when counseling or other nonmedical interventions would be the better choice.

“I’m afraid what we’re getting are false positives and we’ve subjected them to irreversible physical changes,” said Dr Erica Anderson, a clinical psychologist who previously worked at the University of California San Francisco’s gender clinic. “These errors in judgment are fodder for the naysayers – the people who want to eradicate this care.” Anderson, a transgender woman who still treats children with gender dysphoria in her private practice, resigned as president of WPATH’s U.S. chapter last year after her public comments about “sloppy” care prompted the organization to issue a temporary moratorium on board members speaking to the press.

In Europe, concern that too many children might be unnecessarily put at risk has prompted countries like Finland and Sweden that were early to embrace gender care for children to now limit access to care. The United Kingdom is shutting down its main clinic for children’s gender care and overhauling the system after an independent review found that some staff felt “pressure to adopt an unquestioning affirmative approach.”

Ranged against those advising caution in the United States are members of the gender-care community who say that denying treatment to any child with gender dysphoria is unethical and dangerous. “You shouldn’t have to jump through hoops to prove your own trans-ness,” said Dallas Ducar, a psychiatric nurse practitioner and trans health provider in Massachusetts.

Ducar and officials at other clinics said the waiting lists at many facilities show that children already face significant barriers to treatment due to a shortage of providers and a persistent stigma in healthcare attached to transgender patients. “If you put unnecessary roadblocks in the way, we know the kid will still be trans and they will continue to experience deep psychological stress that increases the risk of suicide attempts or suicide itself,” Ducar said.

Dr Marci Bowers, a surgeon specializing in transgender procedures who became WPATH’s president in September, said in an interview that the organization is trying to find a middle ground between “those who basically would have hormones and surgeries available at a vending machine, let’s say, versus others who think that you need to go through all sorts of hoops and hurdles.”

In its new Standards of Care, WPATH retained its longstanding recommendation of comprehensive assessments to determine that adolescents are suitable for medical treatment. “There are no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment,” the guidelines note. Without such evidence, the document adds, “the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time.”

Levine, the U.S. assistant secretary for health, said that clinics are proceeding carefully and that no American children are receiving drugs or hormones for gender dysphoria who shouldn’t. “It’s not like anyone who arrives automatically gets medical treatment,” she said.

A good candidate

Belpre, Ohio, is in Washington County, a rural community of farmhouses, trailer homes and churches set among lush green hills. The area has been home to generations of Boyers. Danielle, 37, works in education. Steve Boyer, a 36-year-old plumber and pipefitter, has served on the board of a local fair, where Ryace and her older brother, Aiden, have shown ducks and lambs they tended. Weekends are spent camping or attending horse shows where Ryace, an accomplished equestrian, competes in barrel races and roping events. “Everybody knows the Boyers,” Steve said.

Steve and Danielle had no direct experience with transgender people when Ryace was born. By around age 4, she referred to herself as a girl, played with girls at friends’ houses and became fascinated with women’s clothing and jewelry. On Christmas morning 2011, shortly before her 4th birthday, Ryace was thrilled when she got much of what she had wanted from Santa: Barbie dolls, a dollhouse, and toys in pink and purple.

But Danielle feared Ryace wouldn’t be accepted as a transgender girl in their conservative community, and she wanted to protect her child from the stares, hateful comments and broken relationships that would inevitably come. “The agreement was, house only,” Danielle said.

Ryace constantly pushed back. From early on, when friends and neighbors complimented her as a cute little boy, she would correct them: She was a girl. Danielle then felt compelled to correct Ryace.

Danielle sought compromises. In elementary school, they often settled on outfits for Ryace of neutral black leggings and brightly colored T-shirts. She picked up dresses and hair pins at yard sales and let Ryace wear them at home. On trips into town, Danielle had Ryace take off the dresses she wore over her boy’s clothes and leave them in the car.

As middle school – and puberty – loomed, Ryace started sneaking bras and mascara to school. She repeatedly texted her mom, “Will you start calling me a girl?”

Television and the internet had opened Ryace’s eyes to new possibilities. She watched “I Am Jazz,” the reality TV show about Jazz Jennings, a transgender girl who socially transitioned at an early age and went on to take puberty blockers and hormones and have surgery. She watched young people on YouTube discuss gender dysphoria and their transitions and saw the before-and-after images they shared. On Instagram, she followed Nikita Dragun, a makeup artist and model who came out as transgender as a teenager and now has 9 million followers.

“This is actually a thing,” Ryace recalled thinking at the time. “I can actually do this.”

Ryace is the type of child that doctors in the Netherlands focused on in their pioneering work in the early 2000s on medical treatment for adolescents with gender dysphoria. Researchers at the Amsterdam University Medical Center methodically screened their subjects to ensure they met certain criteria before receiving treatment. Like Ryace, these adolescents exhibited persistent gender dysphoria from a very early age, lived in supportive environments, and had no serious psychiatric issues that could interfere with a diagnosis or treatment.

The assessments generally lasted about six months before treatment could start. The children filled out a series of questionnaires, and clinicians talked to them frequently to confirm that their gender dysphoria was persistent and to ensure that they understood the long-term implications of treatment. For patients who had psychiatric problems, the researchers extended the assessment phase to more than 18 months before considering medical treatment.

In 2011, the Dutch published detailed results of their work. In one study involving 70 adolescents, the group showed fewer behavioral and emotional problems and fewer symptoms of depression after nearly two years on puberty blockers. Feelings of anxiety and anger were relatively unchanged. All of the patients went on to take hormones.

European countries and the United States adopted the Dutch model for the newly emerging field of gender-affirming care for minors. WPATH and other professional groups issued guidelines recommending comprehensive psychological evaluations before referring any child for medical treatment.

More recently, though, many of the patients flooding into clinics wouldn’t meet Dutch researchers’ criteria. Some have significant psychiatric problems, including depression, anxiety and eating disorders. Some have expressed feelings of gender dysphoria relatively late, around the onset of puberty or after, according to published studies, gender specialists and clinic directors. Such cases require more extensive evaluation to rule out other possible causes of the patient’s distress.

And for reasons not understood, a disproportionate number are patients assigned female at birth. In the NIH study of children’s treatment outcomes now under way, minors designated female at birth made up 61% of enrollees. The gender clinic at Children’s Wisconsin hospital in Milwaukee said 65% of its patients were assigned female at birth. Some researchers and clinics say transgender females are less likely to seek treatment because they face greater social stigma for doing so. Critics of children’s gender care blame peer pressure, reinforced by social media, for boosting the number of transgender males seeking care.

Dr Annelou de Vries, a specialist in child and adolescent psychiatry, is one of the Dutch researchers whose early work established the importance of rigorous patient assessments before starting medical treatment. She said that while she worries about the growing number of children awaiting treatment, the graver sin is to move too fast when puberty blockers and hormones may not be appropriate.

“The existential ethical dilemma in transgender care is between on one hand the (child’s) right for self-determination,” de Vries said. “On the other hand, the do-not-harm principle of medical intervention. Aren’t we intervening medically in a developing body where we don’t know the results of those interventions?” In the United States, in particular, she said, “the transgender right or child’s right seems to be put forward more strongly.” De Vries helped write the section on adolescents in WPATH’s updated Standards of Care. She said she was gratified that language stressing the importance of rigorous patient assessments remained.

In interviews with Reuters, doctors and other staff at 18 gender clinics across the country described their processes for evaluating patients. None described anything like the months-long assessments de Vries and her colleagues adopted in their research.

At most of the clinics, a team of professionals – typically a social worker, a psychologist and a doctor specializing in adolescent medicine or endocrinology – initially meets with the parents and child for two hours or more to get to know the family, their medical history and their goals for treatment. They also discuss the benefits and risks of treatment options. Seven of the clinics said that if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.

“For those kids, there’s not a value of stretching it out for six months to do assessments,” said Dr Eric Meininger, senior physician for the gender health program at Riley Hospital for Children in Indianapolis. “They’ve done their research, and they truly understand the risk.”

“We do not have enough therapists and psychologists who have had adequate training in this area to keep up with the pace of more gender-diverse patients who have come out recently.” Dr Michael Irwig, director of transgender medicine, Beth Israel Deaconess Medical Center

Many clinicians bristle at suggestions they may be moving too fast, treating children before adequately vetting them. Months-long assessments and counseling in lieu of medical treatment puts children at risk, pathologizes them and denies them their fundamental identity, they say. For minors with psychiatric problems, they say, medical treatment often alleviates the distress of gender dysphoria and allows professionals to then address those other conditions.

“Being trans is an identity, not a diagnosis, and transgender people just want the care that affirms who they are,” said Ducar, the trans health provider in Massachusetts.

Ducar and others were disappointed that in its updated Standards of Care, WPATH noted that “social influence” may impact some adolescents’ gender identity. They said the idea of a “social contagion” infecting children perpetuates an offensive misconception that being transgender is a fad spread among impressionable adolescents by friends and social media and fails to recognize the stigma, bullying and discrimination transgender people experience.

Dr Eli Coleman, director of the University of Minnesota Medical School’s Institute for Sexual and Gender Health who oversaw the update of WPATH’s Standards of Care, said: “A knowledgeable and competent clinician can discern between a person’s gender identity that is marked and sustained and an identity that might be socially influenced.”

The issue of assessments is complicated by a chronic shortage of mental-health professionals for children that has only worsened amid soaring rates of depression, anxiety, mood disorders and self harm nationwide.

“We do not have enough therapists and psychologists who have had adequate training in this area to keep up with the pace of more gender-diverse patients who have come out recently,” said Dr Michael Irwig, an associate professor at Harvard Medical School and director of transgender medicine at Beth Israel Deaconess Medical Center. “We are going to miss some people who haven’t been vetted appropriately or who haven’t gotten the mental health care that they need.” That, he said, may increase the number of people who later detransition.

Reuters interviewed parents of 39 minors who had sought gender-affirming care. Parents of 28 of those children said they felt pressured or rushed to proceed with treatment.

Kate, a 53-year-old mother in New Jersey, said she and her husband were shocked in November 2020 when their 13-year-old told them he was transgender. The child, assigned female at birth, had always played with other girls and had never expressly identified as a boy. They just thought their child was a “tomboy.” Now, they learned, he had chosen a male name and wanted to start puberty blockers and get breast-removal surgery.

After an initial one-on-one consultation of little more than an hour with the teen, a psychiatrist said he was a good candidate for puberty blockers, Kate said. An endocrinologist recommended the same after talking with the family for 15 minutes. Kate and her husband also attended a parents’ support group organized by a local gender therapist. Through it all, Kate said, “the message was, let your kid drive the bus. Wherever they lead you, that’s what you should do.”

Kate, who asked that only her first name be used to protect her child’s identity, had read up on puberty blockers. Concerned about their off-label use and possible side effects, she wouldn’t agree to treatment. She supports her son’s social transition, using his preferred pronouns and buying the tape he uses to bind his breasts. But she thinks he is too young to make decisions about life-altering medical treatments.

“Children, when they are 13 or 14, are sometimes totally different people from when they are 18 or 19,” she said. As a result of her decision, her relationship with her son has been “fractured,” Kate said. If he chooses to pursue medical transition after he turns 18, she said, she and her husband won’t be happy, but they won’t stand in the way, either.

Suicide Watch

The fragile truce between Ryace and her parents – girl at home, boy everywhere else – collapsed after Ryace started middle school.

In December 2019, Danielle let Ryace, 11 at the time, wear makeup and black bell-bottom pants to a basketball game at a nearby school. Danielle’s mother, Ruth Alden, was at the game, and afterward, she scolded Danielle. It was embarrassing to the family, Alden said, and other kids are “gonna beat the crap out of her.” Her granddaughter could be driven to suicide, she warned.

Danielle was incensed – and despondent. She felt trapped. She had long worried that she was pushing Ryace toward suicide by insisting that her identity remain a secret. That night, Danielle yelled at her own mother: “What do I do, Mom? Regardless of my decision, I could have a dead child.”

Early in the new year, Danielle, desperate for guidance, joined a Facebook group for Ohio parents of transgender children. That eventually led her to the children’s hospital a two-hour drive away in Akron, for the Aug. 6, 2020, meeting with Dr Crystal Cole and her team.

Dr Cole, an Akron native and specialist in adolescent medicine, founded the hospital’s Center for Gender Affirming Medicine in 2019. The clinic saw 25 patients that year. It now is treating more than 350 young people.

In their two-hour meeting, Cole started with general questions about Ryace, her family and their medical history. Then she sharpened the focus on Ryace’s mental health and readiness for treatment. Danielle exhaled with relief after Ryace responded that she wasn’t hearing voices, wasn’t using illegal drugs and had never tried to harm herself.

The doctor then laid out the treatment options. Ryace could socially transition. She could also opt to receive counseling and therapy to support her through transition. And she could receive treatment to medically transition. At age 12, Ryace was a candidate for puberty suppression to spare her the masculinizing features she feared, with known and unknown risks.

“Ryace is a very vibrant, well-adjusted young lady that just happened to be assigned male sex at birth.” Dr Crystal Cole, Akron Children’s Hospital’s Center for Gender Affirming Medicine

Cole then moved on to the danger of inaction. “The risk of people in the transgender population attempting suicide is over 40%,” she told Ryace and Danielle. “One of the things shown to lower that is affirming care and an affirming environment.”

The statistic Cole referred to came from the 2015 U.S. Transgender Survey, an anonymous online survey of nearly 28,000 transgender adults conducted by the National Center for Transgender Equality, a nonprofit advocacy group. Compared to the 40% of respondents who reported attempting suicide at some point their lives, the rate for the general U.S. population at the time was 4.6%, the authors of the 2015 survey said.

It’s one of several surveys that healthcare professionals cite when advising families with children seeking gender-affirming care. Another was by the Trevor Project, a nonprofit group that focuses on suicide prevention for LGBTQ youth. In that 2021 anonymous survey, 52% of transgender and nonbinary respondents ages 13 to 24 said they had seriously contemplated killing themselves. More than 13,000 survey respondents, or 38% of the overall sample, identified as transgender or nonbinary.

Dr Jonah DeChants, a Trevor Project research scientist, said the group’s survey data “tell a really important story about the mental health impact of being an LGBTQ person and living in a world that tells you that you’re wrong, that you’re an abomination and that you are not safe to be around other children.”

Such online surveys have become common in science, but researchers say they may not be fully representative of the larger population being studied. The authors of the 2015 U.S. Transgender Survey said: “It is not appropriate to generalize the findings in this study to all transgender people.”

Experts in gender care say more specific research is needed to determine whether medically transitioning as a minor reduces suicidal thoughts and suicides compared with those who socially transition or wait before starting treatment.

Some gender-care professionals complain that suicide risk is too often used to pressure and even frighten parents into consenting to treatment. “I think it’s irresponsible for clinicians to do that,” said Anderson, the former president of WPATH’s U.S. chapter. “As a clinical psychologist, I don’t do a suicide assessment by membership in a class. The level of risk varies tremendously across individuals.”

De Vries, the Dutch researcher, told Reuters there is no evidence that “providing care immediately leads to a decline in self harm or would prevent suicide.”

DeChants of the Trevor Project said he wouldn’t want the organization’s data to be used to pressure people on treatment decisions. “We would never say that gender-affirming healthcare is the only way to address suicide risk, but it is an important option for youth, their doctors, and their families to be able to consider,” he said.

After their two-hour evaluation of Ryace, Dr Cole and her team were confident that Ryace had gender dysphoria and was a strong candidate for medical treatment. “Ryace is a very vibrant, well-adjusted young lady that just happened to be assigned male sex at birth,” Cole said. Bringing up suicide on the first visit is scary for a lot of parents, she said, but “it’s a reality we have to ask about.”

A few weeks after visiting Akron, Danielle announced Ryace’s social transition in a Facebook message to family and friends. “I just wanted to let you know that Ryace started JH (junior high) as a female,” she wrote in a Sept. 19, 2020, post. “She can finally be who she feels she is. A girl. I wish this wasn’t our life sometimes but it is and it’s real and I have to let it be and be there to pick up the pieces when the world turns ugly. And it will, so we need all the love and support we can get.”

Many relatives and friends were supportive, including Alden, Danielle’s mother. Others stopped talking to the Boyers. Some parents complained to Ryace’s school about her using the girls’ bathroom. Previously, she had used a single-person bathroom. The principal backed Ryace.

Ryace was eager to begin treatment. “What are we waiting for?” she asked her mother. In November 2020, Danielle took Ryace to an appointment with the Akron clinic’s pediatric endocrinologist to learn more about puberty blockers. The endocrinologist scheduled Ryace for her first injection in March 2021.

Known unknowns

Endo International plc and AbbVie Inc dominate the U.S. market for puberty blockers. The only FDA-approved use for these drugs in children is for central precocious puberty, a condition in which children begin to sexually mature before age 8 or 9 because of pituitary gland dysfunction.

One side effect in children who take these drugs can be a decline in bone density, which is often treated with vitamin D or calcium supplements. Studies have shown that bone density can return to normal once therapy ends, but also that for some transgender girls, it may not.

In September, the FDA published a study that found “no evidence for an increased risk of fracture” for precocious puberty patients who take leuprolide, the generic name for AbbVie’s Lupron and similar drugs. However, the FDA study didn’t review cases of children who took the drug for gender dysphoria.

In a 2018 study published in the medical journal Clinical Pediatrics, researchers at Yale University noted a sharp increase in the off-label use of puberty blockers and said these drugs “have not been thoroughly investigated in populations with normally timed puberty.”

In Texas earlier this year, bone scans indicated that a child, 15 years old at the time, had osteoporosis after 15 months on puberty blockers. The teen’s mother, who asked not to be identified because she works at the hospital where her child was treated, said she thought she had done everything right when her teen came out as a transgender girl. But after the bone scan results, reviewed by Reuters, she said she regretted putting her child on puberty blockers. She stopped the Lupron injections and wouldn’t agree to hormone therapy.

The child, who has socially transitioned, was at first furious with her and threatened to drop out of high school, she said. Their relationship is better now, she said, though “we don’t talk about gender.”

Another concern about puberty blockers emerged in 2016, when the FDA ordered drugmakers to add a warning about psychiatric problems to the drugs’ label as a treatment for children with precocious puberty. On its label for Lupron, AbbVie says: “Psychiatric events have been reported in patients” taking puberty blockers. Events include emotional symptoms “such as crying, irritability, impatience, anger and aggression.”

The FDA pursued the label change after receiving 10 reports through its adverse event reporting system of children who had suicidal thoughts, including one suicide attempt, according to a Dec. 5, 2016, agency report reviewed by Reuters. One of the cases involved a 14-year-old patient taking Lupron for gender dysphoria, the records show. In the report, the FDA said suicidal ideation and depression are “serious events,” and there is “enough evidence to warrant informing prescribers, even in the face of uncertainty about causality.”

The agency also asked drugmakers to closely monitor for these adverse events and file more detailed reports to the agency. “The FDA continues surveillance for psychiatric events associated with drugs indicated for the treatment of pediatric patients with central precocious puberty,” the agency said.

Adverse event reports from medical professionals, consumers and drugmakers help the FDA detect potential safety problems with a drug that may warrant investigation. However, the agency doesn’t receive reports for every adverse event, and there is no certainty that a reported event was caused by a drug. Reports may contain errors, partial data or duplicate information.

Reuters found 72 adverse event reports submitted to the FDA from 2013 through 2021 of children on puberty blockers who showed suicidal, self-injurious, or depressive behavior. The children were taking the drug for central precocious puberty or gender dysphoria or were simply identified as under 18.

A Dec. 17, 2020, adverse event report to the FDA describes a 15-year-old patient taking Lupron for gender therapy. The patient had a history of “major depressive disorder” and a family history of depression. The patient experienced “mental health deterioration” while on Lupron and attempted suicide twice. AbbVie wrote in the report to the FDA that “there is no reasonable possibility” that the adverse events were related to Lupron. The company did not elaborate.

Dr Brad Miller, division director of pediatric endocrinology at the University of Minnesota Medical School and M Health Masonic Children’s Hospital, expressed surprise at the number of adverse event reports Reuters found. He said he was particularly concerned because doctors prescribe puberty blockers for transgender children, who are already at higher risk of mental health problems.

Miller and several other doctors told Reuters they had repeatedly asked AbbVie, Endo and other makers of puberty blockers to seek FDA approval for the drugs in treating gender dysphoria in children and to conduct clinical trials to establish the drugs’ safety for such use. They said the companies always declined. “They would say it would cost a lot of money to get approval,” Miller said. “And they were not interested in going there because (transgender treatment) was a political hot potato.”

AbbVie declined to comment for this article. An Endo spokeswoman said the company has no plans to seek regulatory approval for the use of its drug for any new indications. The company did not respond to requests for further comment for this article.

As prescriptions of puberty blockers increase for off-label gender care, the drugmakers are making cheaper alternatives harder to get.

Endo’s puberty blocker is an implant in the upper arm that releases medication for as long as two years. About a year ago, the company told the FDA that it had discontinued an implant called Vantas that cost about $4,600. That left doctors and patients to use a similar Endo implant called Supprelin LA. It costs about $45,000, according to drug pricing data analyzed by Reuters. Some families with high-deductible insurance plans might have to pay several thousand dollars out of pocket.

AbbVie sells adult and pediatric formulations of Lupron, given by injection every few months. Doctors said that there is no meaningful difference between the two, but that they prefer to use the cheaper adult version, at about $4,700 for a three-month dose. They said insurers sometimes insist on the pediatric version, priced at more than $10,000, when the claim specifies that the patient is a child.

Some scientists and doctors also say they wonder about possible neurological effects of puberty blockers. The question: Hormones released during puberty play a major role in brain development, so when puberty is suppressed, can that result in reduced cognitive function, such as problem solving and decision making?

Dr John Strang, research director of the gender development program at Children’s National Hospital in Washington, D.C., and other researchers wrote in a 2020 paper that “pubertal suppression may prevent key aspects of development during a sensitive period of brain organization.”

Strang said at the time that “we need high-quality research to understand the impacts of this treatment – impacts which may be positive in some ways and potentially negative in others.” He declined to comment on whether he was pursuing such research or funding for it.

At their first meeting at the Akron clinic, Dr Cole was blunt with the Boyers about the unknowns related to puberty blockers and brain development. “We don’t know the long-term effects on cognitive function. It could make it better, worse. We have no idea,” Cole told them. But she said she wouldn’t recommend treatment “if I didn’t see the positive effect on patients.”

Back at the clinic seven months later, Ryace, 13 at the time, smiled in front of a whiteboard where the date, 3-4-21, was written in green marker. It was the day of her first Lupron injection. A photograph of Ryace from that day shows a small glittery bandage on her thigh peeking through her ripped jeans.

The family’s insurance is covering nearly all the cost.

As the months passed, Ryace complained of pain in her knees. She started taking vitamin D as a precaution, and her pain dissipated.

Questions about fertility

Early this year, the Akron clinic told the Boyers that it was time for Ryace to take the next step in her treatment: hormone therapy, to help her develop the feminine characteristics aligned with her gender identity.

Ryace was now 14. In its new guidelines, WPATH makes no age recommendation for hormones.

For decades, hormone therapy has been the central component of treatment to help adults transition – estrogen for transgender women and testosterone for transgender men.

But for children, the choice to take hormones is more complicated. As with much of transgender medicine, research on the impact of hormones on fertility consists of small observational studies or surveys of adults that have significant limitations, experts say.

Many doctors acknowledge that long-term hormone therapy may reduce fertility, and they say children who receive puberty blockers followed by hormones run the highest risk. But with no definitive science to rely on, doctors often leave the question open when talking to children and their parents.

One Tuesday earlier this year, 16-year-old Ethan S. and his mother were in an exam room in suburban Portland to talk about testosterone therapy with Dr Kara Connelly, director of Oregon Health & Science University’s Doernbecher Gender Clinic. After reviewing the family’s medical history, Connelly, an associate professor of pediatric endocrinology, asked Ethan what he wanted from testosterone. “My deepening of the voice definitely, and the, like, distribution of my fat and stuff. And hopefully facial hair,” he said.

Ethan could expect those and other masculinizing changes, Connelly said. A deeper voice and hair growth would be permanent.

Connelly then turned to fertility: Nearly all patients who stop taking testosterone start to have menstrual cycles again, she told them, and they can go on to carry a pregnancy or have their eggs used by someone else. “We can’t predict with 100% certainty that testosterone would not have any effect on your fertility potential,” Connelly said. “All we know is generally what happens in a population, and that it does seem from that evidence that it is not as harmful to fertility potential as we once thought.”

Connelly based her comments on a 2014 study published in the journal Obstetrics & Gynecology that analyzed survey responses from 41 transgender men who had a baby. Twenty-five of them reported using testosterone before becoming pregnant. However, the researchers acknowledged that the survey excluded transgender men “who attempt to get pregnant and cannot and those who do not carry to term.”

Ethan was unconcerned about possible side effects from taking testosterone. “When is the soonest that I can get it?” he asked.

In Oregon, teens can take hormones without parental consent starting at age 15. A social worker handed him a form, and Ethan eagerly signed it.

Ethan’s mother, Melissa, was supportive. She said Ethan had already socially transitioned when he started talking about medically transitioning two years ago. Then Melissa’s father, suffering from alcoholism and depression, committed suicide in February 2021. Ethan had been close with his grandfather, and with that family history, Melissa said she worried even more about her son. “There’s the fear of what happens if I let him transition and then the fear of what happens if I don’t,” Melissa said after the appointment.

Few children choose to have their eggs or sperm preserved before gender treatment as insurance in case they decide they want to try to have children later in life. In particular, harvesting eggs can be expensive and invasive. And for both genders, it can increase the discomfort they experience with their bodies.

Dr Angela Kade Goepferd, a pediatrician and medical director of the gender health program at Children’s Minnesota hospital, sometimes asks parents to write a letter to their future adult child about the decision to start medications that may affect their fertility. An adolescent’s views on starting a family may change over time, so the aim is for the child to remember conversations and choices made when they were younger, Goepferd said, adding: “I don’t think these are easy decisions for families.”

In Akron, Dr Cole tried a similar approach with Ryace. She suggests that her patients try imagining themselves as a 35-year-old and think about what that person might want. “Kids by design don’t tend to think about long-term consequences. That is not how their brains work,” Cole said.

At home, Danielle asked Ryace if she was comfortable with the possibility of being unable to have her own biological children. Ryace said she would adopt. Also, a friend had already offered to have a baby for her after they became adults. “It could be sad, but I’m OK with it,” Ryace told her mother.

By April this year, Ryace was taking estrogen pills along with regular shots of Lupron. The endocrinologist started her on low-dose estrogen, gradually increasing the amount while weaning Ryace from the puberty blocker. Ryace also regularly sees a counselor. The Akron clinic, like many that Reuters spoke to, requires that most teens taking hormones receive counseling to help them through what can be a physically and emotionally challenging time.

‘They’re trying their best’

Ryace lives much of her life as any teenager. But as her transition has progressed, she has continued to confront disapproval from other relatives and the community.

At the county fair last year, members of the crowd grumbled when Ryace was crowned Horse Princess. In town, she spots people rolling their eyes and hears their snide comments. During a field trip in May, she broke down in sobs when she saw students teasing a 16-year-old boy from another school who had flirted with her and had asked to message her online.

Some patients who receive treatments like Ryace’s eventually decide to undergo “bottom surgery.” For transgender girls, the procedure, called vaginoplasty with penile inversion, involves the creation of a vagina and vulva from the patient’s penis and scrotum. Sometimes, the testicles are removed, too. The surgery is irreversible, expensive, and can result in serious complications that require follow-up procedures.

The authors of WPATH’s new standards considered advising that genital surgery generally not be performed until at least age 17, but ultimately they made no age-related recommendations. The Endocrine Society puts it at 18. In its recent policy statement, the Biden administration said gender-affirming surgeries were “typically used in adulthood or case-by-case in adolescence.”

Genital surgeries performed on minors are rare, but surgeons say interest is growing. The Komodo analysis of insurance claims found 56 genital surgeries, including vaginoplasty and other procedures, among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. That doesn’t include surgeries not covered by insurance. In a 2017 research article that surveyed 20 WPATH-affiliated U.S. surgeons, the doctors said there had been “a definite increase in the number of minors” requesting information about vaginoplasty or being referred for surgery by their mental health providers.

Complications from genital surgeries are common. A California study found that a quarter of 869 vaginoplasty patients, with a mean age of 39, had a surgical complication so severe that they had to be hospitalized again. Among those patients, 44% needed additional surgery to address the complication, which included bleeding and bowel injuries.

For adolescents transitioning to female, puberty blockers and hormones can complicate eventual genital surgery. That’s because the medications can stunt development of the male genitalia from which a vagina and vulva are constructed. In 2020, de Vries and other Dutch researchers urged clinicians to inform transgender youth and their parents about this risk when starting puberty blockers.

Bowers, the new WPATH president and a transgender woman, said she has worried that some patients who begin puberty blockers at a young age won’t ever be able to have an orgasm because they never experienced one prior to pausing puberty, regardless of whether they have surgery. She said ongoing research has allayed many of her concerns, and “it seems not only probable but likely there is retention of orgasmic function.” She said she has encouraged doctors to talk about this risk with adolescents before they start medication.

The Akron clinic hasn’t discussed genital surgery with the Boyers yet. Akron Children’s Hospital doesn’t provide gender-affirming surgeries.

Overall, Ryace appears unfazed by the long-term implications of treatment. “I just go along with it pretty much,” she said.

In hindsight, she forgives her mother for making her conceal her identity for so long. “Sometimes she really wasn’t protecting me. She was just hurting me. And I know she didn’t mean it,” Ryace said. “I know a lot of parents probably do that, and they think they’re trying their best.”

Do you have an experience with gender-affirming care to share as a patient, family member or medical provider? Share it with Reuters .

Youth in Transition

By Chad Terhune, Robin Respaut and Michelle Conlin

Photography: Megan Jelinger and Lindsey Wasson

Photo editing: Corrine Perkins

Video editing: Christine Kiernan, Francesca Lynagh and Lucy Ha

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

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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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Transgender children and young people: how the evidence can point the way forward

Philip graham.

University College, London, UK

Associated Data

Data availability is not applicable to this article as no new data were created or analysed in this study.

The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.

Children first begin to develop a sense of biological gender at around the age of 2 to 3 years. 1 At this age, they are able to label pictures of boys and girls according to typical presentations of heteronormativity. At 4 years, boys understand that it is the possession of a penis that marks them out as biologically male and girls understand it is the lack of a penis that means they are biologically female. By this age, children have a sense of the stability of biological gender, an understanding that it remains constant with time. From this point up to the age of 6 or 7 years, their judgement of gender in pictures of clothed children is heavily influenced by appearance so that they label boys pictured in dresses as girls and boys with long hair as girls. By 7 years they recognise biological sex as constant and independent of external appearance. 1

By the age of 7 years, therefore, children understand three different concepts related to sex/gender identity: biological sex, self-perceived gender identity and social gender identity. They understand that they and others are biologically male or female, that they and others have a sense of their own gender identity as male or female and that they and others, depending on their appearance and clothing, are usually perceived by others as male or female. As they develop into adolescence and adulthood, people recognise that, with the use of hormones and surgical interventions, some features of biological sex can be changed. Both self-perceived gender identity and social gender identity may also undergo change.

The great majority of young children develop a self-perceived gender identity consonant with their gender assigned at birth, but some, from the age of 3 or 4 years, develop a self-perceived gender identity which is other than that assigned at birth. This sense of another gender identity can be accompanied by a feeling of discomfort or gender dysphoria. There are many autobiographical examples of the first awareness of gender dysphoria. The best known is that written by Jan Morris, who lived as a highly successful male journalist under the name of James Morris until her mid-30s when, following treatment with hormones, she underwent a surgical reconstruction and thereafter lived as a woman. 2 Jan Morris describes very clearly the onset of her gender dysphoria: 2 ‘I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1). Her sense of discomfort with her assigned gender at birth persisted throughout her childhood, adolescence and early adult life. She describes how, when in role as a young man, she used to pray ‘please God make me a girl’ (p. 39). Gender dysphoria persisted throughout her marriage and parenthood. It was only in her late 30s, after she had had gender reassignment surgery, that she felt at ease.

The majority of prepubertal girls and boys have a clear sense of their own gender identity as female or male. This is nearly always consistent with their gender assigned at birth; in some, like Jan Morris, it is not. In a study of adolescents who had been referred to a gender identity clinic in earlier childhood, Steensma et al were able to show that a high proportion of prepubertal children with gender dysphoria did not continue to show such dysphoria after puberty, 3 a finding that had previously been reported by the same group. 4 Further, children who had shown gender-atypical behaviour (see below) without intense gender dysphoria did not generally show gender dysphoria in adolescence. Those with gender dysphoria who had been assigned a female gender at birth were less likely to desist than those assigned a male gender. Those who persisted were much more likely to have a homosexual or bisexual orientation.

A sense of gender identity must be distinguished from the presence of gender-atypical behaviour, which may occur with or without gender dysphoria. Gender-atypical behaviour (boys behaving like girls and having interests generally regarded as feminine and vice versa ) is not uncommon in the general population. In a total population study, using a standardised instrument, Golombok et al were able to identify 112 boys and 113 girls aged 3.5 years who showed gender-atypical behaviour to an extreme degree. 5 This represented about 2.2% of the population studied (S. Golombok, personal communication, 5 Jan 2021). Especially for girls, there was considerable continuity between gender-atypical behaviours at 3.5 years and such behaviour at the age of 13 years. These investigators do not report whether any of the children in their study were referred for gender dysphoria. The prevalence of 2.2% for gender-atypical behaviour needs to be contrasted with the much less frequent prevalence of 1 per 6800 Dutch adolescents aged 12 to 18 years who requested medical help for gender dysphoria. 6

Gender dysphoria and the onset of sexual feelings

Between 9 and 13 years of age, children start to experience sexual feelings arising from their genitalia. This onset of sexual feelings coincides with biological changes known as gonadarche. At this point, as a result of changes in the hypothalamus and pituitary, the gonads begin to secrete the sex hormones, testosterone and oestradiol, in relatively small quantities. This results in a modest growth of hair around the pubes and in the armpits and growth of the penis and breasts respectively. Spontaneous penile erections and clitoral excitement occur. Around 2 years later, positive feedback occurs in the hypothalamo–pituitary–gonadal axis which stimulates the testes to produce much larger amounts of testosterone and the ovaries to secrete more oestradiol, leading to menstruation. These hormonal changes also result in much more intense experience of sexual desire.

In the majority of children, sexual attraction is heterosexual but around 10% of 16- to 44-year-old adults report some previous sexual contact with a member of the same sex. 7 Most of those who experience homosexual attraction are not transgender. Usually, they have not even shown gender-atypical behaviour; they have been typically masculine, if boys, and feminine, if girls. Transgender boys usually, but not always, feel attraction to others of the same natal sex, i.e. they have homosexual feelings, and transgender girls similarly feel attracted by others of the same natal sex. Inevitably, these sexual feelings are often associated with some degree of confusion and uncertainty. For most transgender boys and girls, however, homosexual feelings have the effect of confirming the child in their transgender role: ‘If I'm really a girl, it isn't surprising I'm attracted to boys’, a transgender natal boy might say to himself and vice versa for girls. But some transgender children develop sexual attraction for others of the opposite natal sex, again with the creation of confusion and uncertainty over the transgender role.

Adolescence and gender identity

Adolescence is a social construction, i.e. it is a phase of life defined by society. 8 In Western society, it is regarded as beginning at the onset of biological puberty. Its end is not, however, defined biologically, but usually by a social criterion such as the age at which the individual develops significant autonomy. In practice, most psychologists, clinicians and members of the general public equate adolescence with the teen years, from 13 to 19, although many young people are well into biological puberty by 13 years and will have completed the biological changes of puberty well before 19 years. Recently, Sawyer and colleagues in an influential article have argued for an expanded and more inclusive definition of adolescence corresponding with the longer period of transition from childhood to adulthood now experienced by young people in Western society. They suggest that the period of 10 to 24 years is more consistent with this experience. 9 It is of relevance that there is considerable variation in ages at onset and termination of biological puberty, some young people normally starting at 10 or 11 years old and others not completing puberty until their later teen years. Relatively recent neuroscientific studies have pointed to the fact that rapid biological changes occur in the brain during the teen years, 10 but these are by no means specific to this phase of life. 11

The general public regard various behaviours as characteristic of adolescence. These may be summarised as impulsiveness, a tendency to take risks, moodiness and fractious relationships with parents. The public image of adolescents accords with this view of ‘the typical adolescent’. It is certainly the case that some teenagers show these characteristics, but population studies suggest that they make up no more than about 10–15% of this age group, 12 although they are certainly the most conspicuous. Another important and, in the context of this article, the most relevant feature of adolescence is thought to be self-questioning about identity. Young people of this age are seen as preoccupied with the question ‘Who am I?’, a question relating to all aspects of their identities, including their gender and sexuality. Such self-questioning is not experienced in intense form by most teenagers. The prevalence of ‘identity problems’ was found to be 14.3% in a group of 15- to 18-year-old American high school students 13 and a similar prevalence of ‘identity distress’ was found in a study of Flemish adolescents and young people aged 14–30 years. 14 The considerable increase in exposure of teenagers in the past 10 to 15 years to social media replete with references to gender identity would make it surprising if there had not been at least some increase of such self-questioning and confusion in this area.

Teenage presentation of transgender

Clinics serving the adolescent transgender population observed a change in the referral pattern after about 2005. Most notably, the gender identity clinic in Toronto, Canada, reported a dramatic increase in referrals at that time. 15 At the Portman Clinic in London (part of the Tavistock and Portman NHS Trust) referrals increased very significantly from 2009 to 2016. 16 At the Tampere University Hospital, Finland, referrals between 2011 and 2013 far exceeded the number expected from the findings of epidemiological studies. 17 This had not been the case previously. There were two other changes in the referral pattern over this period. First, previously, roughly equal numbers of boys and girls had been referred, whereas the increase was associated with much higher numbers of those who had been assigned female gender at birth. Second, previously, the rates of mental ill health among referred children had been about the same as in the general population, 18 whereas now much higher rates of psychiatric disorder, including autism, were reported. 14 , 16

It is therefore clear that from 2005 in Toronto and a few years later in other centres, the characteristics of patients referred to transgender clinics in their early and mid-teen years changed very significantly. In considering the reasons for this new pattern, Aitken et al 15 suggest that one possibility is that, during this period, societal factors made it easier for gay and lesbian youth and their families to seek clinical care. It could be argued, those authors say, that it became easier for girls to ‘come out’ than boys. It might therefore be easier for girls to opt for a transgender identity. Although there is no evidence to this effect, transgender natal girls who found themselves attracted to girls at puberty might have also found it easier to come out as transgender than hitherto. This implies that the increased presentation at adolescence was of girls who had experienced gender dysphoria since their early years. There is another possibility. It is that girls in their teens who are showing mental health problems for other reasons might, searching for an answer to their identity problems or distress, be influenced by social media to question for the first time their gender identity and to see gender change as an answer to their mental dilemmas. This might be more likely if they had previously shown ‘tomboyish’ behaviour. This possibility has been suggested in considering reasons for an increase in referrals of natal girls to a gender identity service between 2009 and 2016. 15 However, both these possibilities remain hypothetical at present and the reasons for the increase in referrals to transgender clinics is unknown.

Although one should not draw conclusions from a single case, it is of interest that one of the claimants in a judicial review brought about because they felt they had been inappropriately treated with puberty blocking drugs gives an account of her transgender development very much in accord with this second possibility. The claimant described a highly traumatic childhood in which she showed many gender-atypical behaviours: ‘ From the age of 14 she began actively to question her gender identity and started to look at YouTube videos and do research on the internet about gender identity disorder and the transition process’ (para. 78). 19

Although some cases of first presentation of transgender in the early teen years may arise from so-called adolescent identity problems or identity distress, it is likely that others do occur because the young person has been reluctant to come out as transgender beforehand, even though gender dysphoria has been present from the early years. Further, it is well established that such reluctance may persist well into adulthood, so that there are a number of recorded cases of people who have waited until their 30s or 40s to make this decision. 20

There is a need for both quantitative and qualitative research to investigate the early histories of girls referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years.

Life for children who are transgender from their early years can be challenging. At home, they have to try to communicate how they feel to potentially sceptical parents. At school, they are likely to experience disbelief, mockery and bullying. To cope they need resilient personalities as well as sensitive and understanding parents who are able to explore and talk openly about their children's feelings with acceptance and without trying to influence decisions one way or another. For, as we have seen, although some prepubertal children persist in their transgender identity, in the course of time many will, for reasons we do not understand, desist. 3 It is remarkable that most children who have been transgender from a young age reach adolescence without developing a higher-than-expected rate of significant mental health problems. 17

Many prepubertal children and their parents will benefit from having available a sympathetic counsellor, psychotherapist or other mental health professional. This will allow exploration of the reasons for the presence of gender dysphoria. Material from voluntary organisations such as Mermaids may be helpful, but parents of young children need to monitor this to ensure that their children are not being encouraged to persist, but are just accepted for what they are at the present time. Difficult decisions about changes of name and the use of toilets need to be negotiated with hopefully sympathetic, open-minded teachers.

As puberty approaches, difficult decisions have to be made. The Amsterdam group has been offering transgender adolescents puberty blockers for 30 years, their first case having been treated in 1991. 21 The group has pioneered an approach to assessment and management of gender dysphoria. It has produced a protocol for medical treatment of transgender children and adolescents that has been widely followed, 22 for example in Italy, Canada, the USA and the UK. The protocol is summarised below and in Box 1 :

• Psychological counselling for children and parents starts well before any medical treatment is considered and continues while such intervention is being administered.
• Once Tanner stage 2–3 is reached, and not before, gonadotropin-releasing hormone analogues (GnRHa) are prescribed where there is a clear indication that this is the appropriate course. This medication is given to block pubertal changes, so that the bodily changes rejected by the young person do not occur. Such treatment is only offered to children and young people aged 12 years and older who have intense gender dysphoria and no significant mental health problems. Informed consent by the young person and by the parents is required. The purpose of the use of puberty blockers is to ensure that young people with gender dysphoria do not live through pubertal bodily changes they find abhorrent. Further, the blocking of pubertal changes means that when, as is nearly always the case, transgender adults choose to have at least some degree of gender reassignment surgery, some procedures, particularly bilateral mastectomy for those assigned female gender at birth, will not be necessary.
• With careful assessment and selection, a very small minority of young people prescribed puberty blockers (between 1.4 and 3.5%) change their minds and do not wish to proceed further. 23 For the large majority who do wish to proceed, around the age of 16 years or older, cross-sex hormones are prescribed. For this treatment to be started, the young person must be living in the role of the preferred gender. Again, informed consent by the young person and, preferably, the parents is required.
• At the age of 18 years or older, those (again the great majority) who meet eligibility criteria can begin the process of gender reassignment surgery. Such surgery occurs variably according to the degree and at the pace desired by the individual concerned.

Management of gender dysphoria 22

• Make a full assessment as early as possible
• Follow with supportive counselling throughout childhood and adolescence
• Subsequent interventions should only take place with informed consent, first by parents and then by the young person, with reflection before each phase
• If intense gender dysphoria persists, consider using puberty blockers at Tanner stages 2–3
• Consider use of cross-sex hormones at age 16
• At age 18–19 and subsequently, consider gender reassignment surgery

Effectiveness of treatment

The aims of treatment are twofold:

• to explore with the child or young person with gender dysphoria the reasons for their discomfort with their gender assigned at birth and to consider alternative ways forward, including living in the role of their birth-assigned gender or pursuing medical intervention that will enable them to transition;
• in those who choose to live in their preferred transgender role, to start treatment, pausing for reflection before each step, first with puberty blockers, then with cross-sex hormones and finally with gender reassignment surgery to relieve gender dysphoria.

Among those who opt for medical treatment, the degree of success of intervention is measured by the absence of gender dysphoria and mental health problems and by the presence of psychological well-being. Ideally it would be possible to quote findings from a number of controlled trials of each of the interventions. Given the impracticability of obtaining agreement from children and young people with intense gender dysphoria to participate in controlled trials, the findings from uncontrolled but carefully conducted studies provide the main evidence for effectiveness.

There have now been a number of such uncontrolled studies, in which patients have been followed up to see whether their physical and psychological states have improved or deteriorated after the use of puberty blockers alone 24 – 26 and puberty blockers followed by cross-sex hormones followed by surgery. 27 – 29 The most recently published study of the effects of puberty blockers was reported from the Portman Clinic, London. 30 This study reported on the short-term outcome over 2 years of 44 children and young people aged 12 to 15 years when they started treatment with puberty blockers. Overall, the patient experience was positive. Although there were some children who showed some negative outcomes in mood and quality of relationships with family and friends, the majority showed positive change. There was no change in the rate of parent- or child-rated behaviour problems or risk of self-harm. All adverse effects, when they occurred, were mild. In line with other studies, only 1 of the 44 children and young people treated with puberty blockers did not go on to request cross-sex hormone treatment.

All the studies quoted above have provided valuable information. In all cases, there has been benefit from the interventions for the majority and an absence of significant harm. The most recent critical review of the use of puberty blockers has concluded: ‘Although large long-term studies with diverse and multicultural populations have not been done, the evidence to date supports the finding of few serious adverse outcomes and several potential positive outcomes. This literature suggests the need for transgender youth to be cared for in a manner that not only affirms their gender identities but that also minimises the negative physical and psychological outcomes that could be associated with pubertal development’. 31 In all published cases, the majority has reported benefit from the interventions and an absence of significant harm. Where it has been measured, an improvement in psychological well-being has always been found. It is well established that adults who transition ‘experience fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction’ than before the transition and show no wish to revert to their gender assigned at birth. 32

It should be added that the use of puberty blockers in early adolescence has been strongly criticised. 33 , 34 It has been claimed that there has been undue reliance on an affirmative approach (self-identification) in making a transgender diagnosis, that the complexity of the underlying problems of young people presenting as transgender has been inadequately assessed, that a high proportion of those who are treated with puberty blockers regret that they have received this treatment and that the young people who have been treated have not been capable of giving informed consent to treatment that has such profound implications for their future.

Adverse effects of medical interventions

The effect of puberty blockers is generally, though not universally, regarded as reversible. Their use has been associated with apparently reversible stunting effects on height velocity and bone maturation. 29 , 35 General cautions that have been expressed by clinicians about the possibility of irreversibility, such as those by Professor Butler and Dr de Vries quoted in a judicial review, 19 are no more than one might expect in relation to a large number of interventions in routine use. Caution about possible harm is always an appropriate clinical stance. It should not be taken to mean that the intervention in question should not be used where it is indicated.

There is one undeniable loss that occurs as a result of the use of puberty blockers. The individual does not go through the experience of the ‘normal’ adolescence he or she would have had without their use. However, most transgender young people do not consider this to be a loss or in any way regrettable.

The use of cross-sex hormones exposes the individual to the risk of a metabolic abnormality in about 15% of cases, but the significance of this finding is not clear and it does not seem a contraindication to their use. 36 Further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones.

Informed consent

The competence of young people to give informed consent to the use of puberty blockers and cross-sex hormones is currently a matter of great relevance to clinical management. In UK law, 16 years is regarded as the youngest age at which it can be assumed, on the basis of chronological age, that a young person can give informed consent to a medical procedure. Below that age, it is widely accepted that, in considering whether a young person is capable of giving informed consent, the so-called Gillick principle should be applied. This principle, expressed by Lord Scarman in a 1985 House of Lords judgment and repeated in the above-mentioned judicial review, 19 is that ‘as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to […] understand fully what is proposed’. There is a controversy as to whether, because of the unusually complicated issues involved, children under the age of 16 could ever have the cognitive competence to give consent to puberty blockers or cross-sex hormones. This matter was considered in great detail in the judicial review whose judgment was published in December 2020. 19 This court decided that young people under 16 years could not give informed consent to the use of puberty blockers. Further, the court ruled that, even in cases where parents give their informed consent and clinicians are in agreement, an application should be made to the courts for authorisation before a child under 16 years can be administered puberty blockers. However, on appeal, this decision was reversed. The Appeal Court decided that the initial judgment had placed an improper restriction on the Gillick test and that it would not be appropriate for an application to the courts to be required before a child could be administered puberty blockers. 37

There is a need for systematic psychological investigation into the capacity of children and young people to make decisions in this area. Although there is some evidence on the capacity of young people aged 14–16 years to understand medical procedures, there is no evidence relating to the specific question of their understanding of the use of puberty blockers and cross-sex hormones, for example, in comparison with that of older people. Such evidence should be obtained. In the meantime, it would seem reasonable to rely on the findings of Weithorn & Campbell, whose study provides the most relevant data. 38 These investigators looked at 24 individuals in each of four age groups: 9, 14, 18 and 21 years. They tested their competence to make informed treatment decisions in a series of medical dilemmas, involving conditions such as epilepsy, diabetes and psychological problems. The children, adolescents and young adults were given the nature of the problem, treatments options, expected benefits, possible risks and consequences of failure, and then assessed on how much they understood. The 14-year-olds did as well as the 21-year-olds. The 9-year-olds did distinctly less well. Although it is many years since this study was carried out, until more relevant evidence is produced, there is no reason why its findings should not be regarded as highly pertinent.

Conclusions

One can conclude from the evidence that gender dysphoria is a relatively rare but well-defined condition, characterised by a strong desire to be of the gender opposite to that assigned at birth and by an insistence that one is, indeed, of the other gender. Affected transgender individuals are usually aware of its existence by the age of 5 years. Gender dysphoria needs to be distinguished from gender-atypical behaviour, where those assigned male gender at birth showed an interest in activities generally preferred by girls and vice versa . Marked gender-atypical behaviour occurs in around 2–3% of the population, most of whom are not transgender. Further, many children who show gender dysphoria before puberty do not continue to do so during and after pubertal changes occur. However, if gender dysphoria does persist into adolescence, its intensity tends to increase at this time.

From about 2005 until the present, there has been a considerable, perhaps tenfold, increase in the number of children and young people referred to gender identity clinics. This change has been observed not just in the UK, but in Canada, the USA and Finland. These more recent referrals have differed from previous cases in three ways. More recent referrals have been older, often not presenting until the early teen years. Whereas previously referrals were relatively evenly balanced between those assigned male and female gender at birth, there is now a considerable preponderance of those assigned female gender at birth. Further, whereas previously children and young people with transgender did not show high rates of behavioural and emotional disturbance, this is not the case for recent referrals.

The assessment and management of gender dysphoria has been pioneered by a Dutch group based in Amsterdam. This group has laid down a number of principles of management, which have been widely adopted by gender identity clinics in other countries. The effectiveness of this sequence of interventions is now reasonably well established, with good evidence that it relieves gender dysphoria and usually improves psychological well-being. Physical side-effects may occur but as far as can be ascertained at present, not to a degree where possible harm outweighs benefit. There are, however, unresolved issues concerning the capacity of young people with gender dysphoria to give informed consent to the use of puberty blockers.

There are a number of gaps in knowledge requiring urgent attention. First, it is unclear whether the considerable increase in referrals to gender identity clinics in the past 15 years is due to greater willingness of early affected individuals to come out at this age or whether clinics are dealing with a different population with different needs. There is clearly a need for both quantitative and qualitative research to investigate the early histories of those assigned female gender at birth referred with gender dysphoria for the first time in adolescence. Such research should include interviewing parents about their children's early years. Second, although it is reasonably well established that the use of puberty blockers is not accompanied by serious adverse effects, further research is required on the nature of possible metabolic abnormalities arising from the use of cross-sex hormones. Finally, there is a need for research into the capacity of children and young people, compared with older people, to understand the implications of the use of puberty blockers and cross-sex hormones.

About the author

Philip Graham is Emeritus Professor of Child Psychiatry in the Institute of Child Health, University College, London, UK.

Data availability

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of interest