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Transgender Research in the 21st Century: A Selective Critical Review From a Neurocognitive Perspective

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1 From the Department of Experimental Clinical and Health Psychology, Ghent University; and the Department of Endocrinology and the Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium.
PMID: 29050504
DOI: 10.1176/appi.ajp.2017.17060626

Gender dysphoria describes the psychological distress caused by identifying with the sex opposite to the one assigned at birth. In recent years, much progress has been made in characterizing the needs of transgender persons wishing to transition to their preferred gender, thus helping to optimize care. This critical review of the literature examines their common mental health issues, several individual risk factors for psychiatric comorbidity, and current research on the underlying neurobiology. Prevalence rates of persons identifying as transgender and seeking help with transition have been rising steeply since 2000 across Western countries; the current U.S. estimate is 0.6%. Anxiety and depression are frequently observed both before and after transition, although there is some decrease afterward. Recent research has identified autistic traits in some transgender persons. Forty percent of transgender persons endorse suicidality, and the rate of self-injurious behavior and suicide are markedly higher than in the general population. Individual factors contributing to mental health in transgender persons include community attitudes, societal acceptance, and posttransition physical attractiveness. Neurobiologically, whereas structural MRI data are thus far inconsistent, functional MRI evidence in trans persons suggests changes in some brain areas concerned with olfaction and voice perception consistent with sexual identification, but here too, a definitive picture has yet to emerge. Mental health clinicians, together with other health specialists, have an increasing role in the assessment and treatment of gender dysphoria in transgender individuals.

Keywords: Affective Disorders; Gender Dysphoria; Review; Suicidality; Transgender.

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Published: 26 November 2021

How four transgender researchers are improving the health of their communities

Tara Santora 1

Nature Medicine volume 27 , pages 2074–2077 ( 2021 ) Cite this article

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Being transgender can inspire these researchers and improve their work, but sometimes their research has nothing to do with their identity.

Whether as a researcher or a healthcare worker, it is difficult to break into medicine as a transgender person. Trans identity is a double-edged sword of invisibility and hypervisibility. On the one hand, trans people are probably under-represented in the field, which can make it difficult to find role models and representation. Trans people may have to fight for trans-inclusive policies that no one has thought to instate before, such as being allowed to use a chosen name rather than a legal name in internal documents and on scientific papers. On the other hand, trans scientists often feel compelled to speak out about inclusion despite the threats of discrimination and verbal abuse.

It is impossible to tell just how under-represented trans people are in science, because they have been systematically excluded from diversity counts. Many surveys that could yield this type of information, such as the 2022 Survey of Earned Doctorates , ask about sex instead of gender and give only the options of ‘male’ and ‘female’.

Recently, some organizations have begun to include trans people in their data collection. The American Association of Medical Colleges’ Matriculating Students Questionnaire , for example, has found a slow but steady rise in trans medical students in recent years, with 0.8% of the 2020 matriculating class identifying as transgender, up from 0.6% in 2017. The 2020 class includes 22,239 students, so about 156 of these future doctors are transgender. This implies that there are a substantial number of trans people in medicine already. Exactly how many is not known.

Nature Medicine spoke to four transgender medical professionals and researchers about what inspires their research, trans inclusivity in science and medicine, and the unique challenges and successes of being trans in these fields.

Ayden Scheim is an assistant professor of epidemiology and biostatistics at Drexel University in Pennsylvania. He researches the health impacts of stigma and discrimination on marginalized populations. James Mungin is a senior PhD candidate in the Department of Microbiology, Immunology, and Physiology at Meharry Medical College in Tennessee. Before pursuing their PhD, Mungin spent six years researching infectious diseases and drug development at the Albert Einstein College of Medicine in New York, the United States Department of Agriculture, and Tuskegee University in Alabama. Kale Edmisto n is an assistant professor of psychiatry at the University of Pittsburgh. He is a sensory neuroscientist and studies mood and anxiety disorders. Michelle Ross is a psychotherapist and is a co-founder and Director of Holistic Wellbeing Services at CliniQ, a holistic wellbeing and sexual-health service for transgender, non-binary and gender-diverse people, run in partnership with Kings College Hospital, London. She has more than 30 years of experience in sexual health, human immunodeficiency virus and holistic wellbeing.

Ayden Scheim: Research must involve the community

Ayden Scheim did not follow a traditional career path. The sociology major chose to pursue epidemiology only after being seated next to his future principal investigator at a wedding. Speaking with her, he realized that the field just so happened to fit his exact goals in life.

“I chose to go into epidemiology because I saw the opportunity to be involved in trans health research that was really going to be directly relevant to changing policies and changing healthcare practices,” Scheim says. “That sort of applied aspect attracted me at the time, and it’s become more attractive the longer I’m in this work.”

Although Scheim’s experience as a transgender man informs his work, he does not overly rely on it. “To be frank, as a white trans man who transitioned 18 years ago, with every year that goes by, I think that my own personal experience becomes less useful for my research,” he says. Scheim asks questions of local community members to understand their needs, whether that be how trans women of color experience discrimination or what gender-affirming care looks like today. Gender-affirming care may include medical treatments such as hormone therapy or surgery, as well as non-medical care such as speech therapy and facial hair removal.“[There are] so many questions my own personal experience does not give me any special insight on,” he says.

To be sure that Scheim’s research best supports the community, he involves trans people at every stage of his projects. For example, Scheim, who is originally from Canada, investigates the experiences of trans people there through Trans PULSE Canada , of which he is a co-principal investigator. For a recent survey, he identified subpopulations of the trans community in Canada who had not been purposefully included in past research, including sex workers, Indigenous people and disabled people. Committees of trans people with these identities were crucial to helping him develop survey questions.

For Scheim, involvement must be tangible and continuous. “It’s not just about community engagement, but it’s about the [transgender] community having control over the research process and over major decision-making,” Scheim says. Part of that means remaining flexible to meet the needs of transgender people. During the COVID-19 pandemic, Scheim’s team was deep in analysis of data they had collected in 2019. But at the behest of the trans community, they put this research on hold to survey trans people about how COVID-19 impacted them, such as by affecting their mental health or interrupting their access to gender-affirming hormones or surgery.

Scheim, who has a tendency to overbook himself, is also involved in a research project in India investigating the healthcare needs of transgender men and transmasculine non-binary people there. Indian trans women colleagues asked him to consult on the project, and that consultation turned first into grant-writing and then into becoming a major player. “I try not to insert myself in new contexts where I’m an outsider or a guest, but rather work where I’m invited,” he says. As with the Canadian study, Scheim and his colleagues ask Indian transmasculine people to provide input throughout the process.

Scheim has been researching trans health for 15 years. But despite the impressive number of projects he has led, he says that he is not always respected for his work. Sometimes people credit his expertise to being a trans man and not to his substantial contributions to the field. He wishes that cisgender colleagues would see him as an expert because of his academic work and not just because of his personal identity.

That being said, being trans is important to his work. “There’s an ongoing struggle to assert that trans health research be led by trans people,” he says. In the field of epidemiology, that is exactly what he is doing.

James Mungin: Educate the marginalized

James Mungin focuses on the microscopic. They are invested in the future of nanotechnology for drug delivery and are writing their thesis on the molecular mechanisms of vaginal transmission of Zika virus. But they also go big. For years, Mungin has devoted their energy to health education targeting fellow members of the queer Black community.

“I grew up in under-represented communities. I’m Black, queer, and trans non-binary,” they say. “Having that personal experience, I want to bring that to the scientific space, and also go to the community and bring my scientific expertise there.”

One way that Mungin does this is through sexual-health education. They are passionate about human immunodeficiency virus (HIV) prevention because of the disproportionate effect this epidemic had and continues to have on queer Black and brown men. They have volunteered for several local HIV-prevention projects for people of color, including by serving on a community advisory board. “I have a commitment as far as what I can do to shift how BIPOC [Black, Indigenous, People of Color] think about sexual health,” Mungin says.

Because of their history with health education, it was only natural that Mungin would turn to teaching their community about COVID-19 when the pandemic hit. “One of the things I noticed was there was a lot of misinformation and conspiracy theories. And so I just kind of wanted to, like, level that out,” they say.

One way Mungin tackles misinformation is through participating in panels and workshops. For example, they recently spoke about the vaccines against COVID-19 on a panel of medical professionals who were all people of color. Mungin has also adapted their Instagram account — @blackqueerscientist — to further their outreach. Through it, they have engaged more than 1,700 followers by providing information about COVID-19 in a way that specifically appeals to their demographic.

Their social media campaign is not huge, and it is not meant to be. It is meant to appeal to a specific population that is often ignored by science communicators. “I talk about science, but again, from more of a Black, queer, trans non-binary lens,” Mungin says. In an Instagram post, they wrote, “The level of fear and frustration my people experience is so intense that I wanted to find a solution to alleviate these pains.” Through informative graphics and videos, Mungin explains topics such as long COVID and how the virus affects pregnancy. They also express their understanding of why members of the Black community do not trust the vaccines, but Mungin makes it clear that they do and lays out why others should too.

In addition to bringing their scientific expertise to their community, Mungin also brings their personal experiences to the lab. Often this means pushing colleagues to think about inequalities in science and medicine, such as by starting conversations about whether a drug that researchers are developing will be accessible to everyone who needs it.

This year, Mungin will graduate with their PhD from Meharry Medical College. They hope to further their career as a postdoctoral researcher and study nanotechnology for targeted drug delivery to treat sexually transmitted infections. However, finding a research position is not all they have to worry about. At Meharry, people are accepting of Mungin as non-binary, but there is no guarantee that will be true wherever they end up. Mungin is not asking their peers to be perfect, but to put in the effort to be inclusive. “[My colleagues] may misgender me from time to time, but I think as long as you’re trying and giving effort, that’s something that I can rock with,” they say.

Kale Edmiston: Being trans does not define my research

Kale Edmiston is performing innovative research on how anxiety intersects with the visual system. Anxious people are more likely to interpret visual information as threatening, so he is experimenting with electrically stimulating the visual cortex to decrease activity in this region of the brain. He hopes that this stimulation could reduce symptoms of anxiety and could one day lead to a new way of treating the condition.

But when he is interviewed about his work by journalists, Edmiston finds that his research does not get the focus it deserves. He is instead asked questions that try to draw out links between his neuroscience work and his identity as a trans man. Those connections do not exist, he says. He has been asked “How does transness impact your work or inspire it?” But it does not.

This does not mean that Edmiston’s trans identity is completely separate from his work life. His secondary professional focus after mood and anxiety research is improving healthcare experiences for trans people. He has been working to improve healthcare experiences for nearly as long as he has been studying neuroscience, but these two aspects of his career remain separate.

“Trans communities everywhere are under-resourced. But in the South [of the USA], it’s just really awful,” he says. So Edmiston started going to doctor’s appointments with transgender people he did not know, such as friends of friends, and created a referral list of trans-competent providers. This work quickly became more than Edmiston could handle on his own, so he co-founded the Trans Buddy Program to get others involved. When Edmiston moved to the University of Pittsburgh, where he is now a professor, he started a local branch of the Trans Buddy Program.

“There’s a general culture of trans people not trusting the healthcare system, and there’s lots of really good reasons for that. But because of that, trans people frequently delay care and may not feel comfortable making appointments in the first place. When they do, they may not feel comfortable being forthright with a provider,” Edmiston says. “Having another person in the room, and having a list of providers that have been vetted by the community, those things can help to facilitate communication and build trust.”

Edmiston is also working on a project to write health-promotion materials for trans people. When most trans people come out, they do not know how to access transition-related services. “There’s a really long tradition of trans people sharing that knowledge amongst each other and helping guide people through that. But because all of that knowledge is shared via word of mouth, it may not necessarily be shared [widely],” he says. The Trans Buddy Program was started to make this information more accessible.

As a neuroscientist, Edmiston does not study trans people’s brains, but he does have thoughts on those who do. “I really wish that people would stop trying to focus on the neural correlates of transness. I think it’s really wrongheaded,” he says. “In the 90s, there was all this research of like, ‘Why are people gay? Let’s try and figure out the biological cause of being gay. Once we figure that out, then people won’t be homophobic anymore,’” he says. “The obvious response to that is you should just be accepting of people, no matter what.”

Instead, Edmiston would like to see more research on interventions that could improve trans lives. “There’s so much mental health disparity in the trans population. And there’s been a lot of work describing that problem for many years now,” he says. “I would love to see a shift towards mental health interventions that are designed with the trans community in mind.”

Michelle Ross: Trust takes time and effort

As a trans woman and a psychotherapist, Michelle Ross began their career by helping gay and bisexual men cope with the HIV epidemic through psychotherapy. As she continued in this field, Ross (who uses ‘she’ and ‘they’ pronouns interchangeably) learned that trans women like herself face a disproportionate HIV burden. They also have unique concerns, such as how feminizing hormones interact with HIV medications . To support these concerns, Ross began dedicating mental-health and sexual-health services to trans people in 2007. Recognizing the importance of this work, Ross surveyed the local trans community in London about their needs and opened CliniQ in 2012 as a space where trans people of all ages can receive sexual-health and holistic wellbeing services.

At other clinics, trans people are often misgendered by being called their birth name rather than their correct name, and by use of the wrong pronouns. They may be asked inappropriate and unnecessary questions about their sexuality and relationships. But because CliniQ is run mostly by trans people, with all cisgender employees and volunteers given in-depth training, it provides a much safer atmosphere for trans care. “You can’t buy that trust. You have to earn it,” Ross says.

CliniQ partners with King’s College Hospital in London to offer health services such as cervical cancer screening, which can often be uncomfortable for trans people. The medical professionals work with the patients to make them feel as safe as possible, such as by allowing them to insert the speculum themselves. If this sort of exam is traumatizing, there are counselors waiting to help patients process the experience.

Sexual-health services such as Pap smears and screening for sexually transmitted infections can be intimidating, so CliniQ has turned the weekly walk-in clinics into a lively event. Before the COVID-19 pandemic, they transformed a hospital waiting area into a community space with tea, coffee, fruit and sandwiches. Friends would meet there, and it was not uncommon for someone to play a guitar or juggle. “It’s like going home,” Ross says of these sessions. Twenty to thirty patients would receive services in a three-hour window.

Unfortunately, COVID-19 has changed that. The clinic took a three-week break, and when it returned, only three people were allowed in the waiting room at a time, with masks and social distancing. Now that many patients are vaccinated, the service has expanded to 12 appointments each Tuesday, with more becoming available soon. In CliniQ itself, demand has skyrocketed during the pandemic, particularly for teletherapy.

Beyond supporting trans people through the pandemic, Ross has big goals for CliniQ. Recently, for the first time, the United Kingdom began collecting data on trans people with HIV. This data will allow researchers to quantify how many trans people are affected by HIV. Now Ross wants the country to collect information about the prevalence of other sexually transmitted infections in the trans community. These data, or lack thereof, inform everything from CliniQ’s funding to staffing to services. “Without data, you’re invisible!” she says. “If you don’t count us, we don’t count.”

Ross also plans to expand CliniQ to cities in the United Kingdom outside of London. But she hopes that one day that will not be necessary. “We don’t want to build an empire,” they say. She would rather trans people be able to go to any health provider and receive adequate and respectful care. “We want to make sure that we’re not needed,” they say. But until that time, Ross and CliniQ will be there to care for their community.

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Santora, T. How four transgender researchers are improving the health of their communities. Nat Med 27 , 2074–2077 (2021). https://doi.org/10.1038/s41591-021-01597-y

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Transgender Research in the 21st Century: A Selective Critical Review From a Neurocognitive Perspective

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What does the scholarly research say about the effect of gender transition on transgender well-being?

We conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. We identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. We found no studies concluding that gender transition causes overall harm. As an added resource, we separately include 17 additional studies that consist of literature reviews and practitioner guidelines.

Bottom Line

This search found a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals. The literature also indicates that greater availability of medical and social support for gender transition contributes to better quality of life for those who identify as transgender.

Below are the 8 findings of our review, and links to the 72 studies on which they are based. Click here to view our methodology . Click here for a printer-friendly one-pager of this research analysis .

Suggested Citation : What We Know Project, Cornell University, “What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being?” (online literature review), 2018.

Research Findings

1. The scholarly literature makes clear that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals.

2. Among the positive outcomes of gender transition and related medical treatments for transgender individuals are improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidality, and substance use.

3. The positive impact of gender transition on transgender well-being has grown considerably in recent years, as both surgical techniques and social support have improved.

4. Regrets following gender transition are extremely rare and have become even rarer as both surgical techniques and social support have improved. Pooling data from numerous studies demonstrates a regret rate ranging from .3 percent to 3.8 percent. Regrets are most likely to result from a lack of social support after transition or poor surgical outcomes using older techniques.

5. Factors that are predictive of success in the treatment of gender dysphoria include adequate preparation and mental health support prior to treatment, proper follow-up care from knowledgeable providers, consistent family and social support, and high-quality surgical outcomes (when surgery is involved).

6. Transgender individuals, particularly those who cannot access treatment for gender dysphoria or who encounter unsupportive social environments, are more likely than the general population to experience health challenges such as depression, anxiety, suicidality and minority stress. While gender transition can mitigate these challenges, the health and well-being of transgender people can be harmed by stigmatizing and discriminatory treatment.

7. An inherent limitation in the field of transgender health research is that it is difficult to conduct prospective studies or randomized control trials of treatments for gender dysphoria because of the individualized nature of treatment, the varying and unequal circumstances of population members, the small size of the known transgender population, and the ethical issues involved in withholding an effective treatment from those who need it.

8. Transgender outcomes research is still evolving and has been limited by the historical stigma against conducting research in this field. More research is needed to adequately characterize and address the needs of the transgender population.

Below are 51 studies that found that gender transition improves the well-being of transgender people. Click here to jump to 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being.

Ainsworth and spiegel, 2010.

Ainsworth, T., & Spiegel, J. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research , 19 (7), 1019-1024.

Objectives: To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery. Methods: Facial Feminization Surgery outcomes evaluation survey and the SF-36v2 quality of life survey were administered to male-to-female transgender individuals via the Internet and on paper. A total of 247 MTF participants were enrolled in the study. Results: Mental health-related quality of life was statistically diminished (P < 0.05) in transgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. There was no statistically significant difference in the mental health-related quality of life among transgendered women who had GRS, FFS, or both. Participants who had FFS scored statistically higher (P < 0.01) than those who did not in the FFS outcomes evaluation. Conclusions: Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

Bailey, Ellis, & McNeil, 2014

Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt

Bailey, L., Ellis, S. J., & McNeil, J. (2014). Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. The Mental Health Review , 19 (4), 209-220.

Purpose: The purpose of this paper is to present findings from the Trans Mental Health Study (McNeil et al., 2012) – the largest survey of the UK trans population to date and the first to explore trans mental health and well-being within a UK context. Findings around suicidal ideation and suicide attempt are presented and the impact of gender dysphoria, minority stress and medical delay, in particular, are highlighted. Design/methodology/approach: This represents a narrative analysis of qualitative sections of a survey that utilised both open and closed questions. The study drew on a non-random sample (n 1⁄4 889), obtained via a range of UK-based support organisations and services. Findings: The study revealed high rates of suicidal ideation (84 per cent lifetime prevalence) and attempted suicide (48 per cent lifetime prevalence) within this sample. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk within this sample. Research limitations/implications: Due to the limitations of undertaking research with this population, the research is not demographically representative. Practical implications: The study found that trans people are most at risk prior to social and/or medical transition and that, in many cases, trans people who require access to hormones and surgery can be left unsupported for dangerously long periods of time. The paper highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritise timely intervention and support. Originality/value: The first exploration of suicidal ideation and suicide attempt within the UK trans population revealing key findings pertaining to social and medical transition, crucial for policy makers, commissioners and practitioners working across gender identity services, mental health services and suicide prevention.

Bar et al., 2016

Bar, M. A., Jarus, T., Wada, M., Rechtman, L., & Noy, E. (2016). Male-to-female transitions: Implications for occupational performance, health, and life satisfaction. The Canadian Journal of Occupational Therapy , 83 (2), 72-82.

Background. People who undergo a gender transition process experience changes in different everyday occupations. These changes may impact their health and life satisfaction. Purpose. This study examined the difference in the occupational performance history scales (occupational identity, competence, and settings) between male-to-female transgender women and cisgender women and the relation of these scales to health and life satisfaction. Method. Twenty-two transgender women and 22 matched cisgender women completed a demographic questionnaire and three reliable measures in this cross-sectional study. Data were analyzed using a two-way analysis of variance and multiple linear regressions. Findings. The results indicate lower performance scores for the transgender women. In addition, occupational settings and group membership (transgender and cisgender groups) were found to be predictors of life satisfaction. Implications. The present study supports the role of occupational therapy in promoting occupational identity and competence of transgender women and giving special attention to their social and physical environment.

Bodlund and Kullgren, 1996

Transsexualism--general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex

Bodlund, O., & Kullgren, G. (1996). Transsexualism–general outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex. Archives of Sexual Behavior , 25 (3), 303-316.

Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

Bouman et al., 2016

Sociodemographic Variables, Clinical Features, and the Role of Preassessment Cross-Sex Hormones in Older Trans People.

Bouman, W. P., Claes, L., Marshall, E., Pinner, G. T., Longworth, J., et al. (2016). Sociodemographic variables, clinical features, and the role of preassessment cross-sex hormones in older trans people. The Journal of Sexual Medicine , 13 (4), 711-719.

Introduction: As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. Aims: The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. Methods: Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. Main Outcome Measures: Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire). Results: The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n = 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained. Conclusion: The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.

Boza and Nicholson, 2014

Gender-Related Victimization, Perceived Social Support, and Predictors of Depression Among Transgender Australians

Boza, C., & Nicholson Perry, K. (2014). Gender-related victimization, perceived social support, and predictors of depression among transgender Australians. International Journal Of Transgenderism , 15 (1), 35-52.

This study examined mental health outcomes, gender-related victimization, perceived social support, and predictors of depression among 243 transgender Australians (n= 83 assigned female at birth, n= 160 assigned male at birth). Overall, 69% reported at least 1 instance of victimization, 59% endorsed depressive symptoms, and 44% reported a previous suicide attempt. Social support emerged as the most significant predictor of depressive symptoms (p>.05), whereby persons endorsing higher levels of overall perceived social support tended to endorse lower levels of depressive symptoms. Second to social support, persons who endorsed having had some form of gender affirmative surgery were significantly more likely to present with lower symptoms of depression. Contrary to expectations, victimization did not reach significance as an independent risk factor of depression (p=.053). The pervasiveness of victimization, depression, and attempted suicide represents a major health concern and highlights the need to facilitate culturally sensitive health care provision.

Budge et al., 2013

Budge, S. L., Katz-Wise, S. L., Tebbe, E. N., Howard, K. A. S., Schneider, C. L., et al. (2013). Transgender emotional and coping processes: Facilitative and avoidant coping throughout gender transitioning. The Counseling Psychologist , 41 (4), 601-647.

Eighteen transgender-identified individuals participated in semi-structured interviews regarding emotional and coping processes throughout their gender transition. The authors used grounded theory to conceptualize and analyze the data. There were three distinct phases through which the participants described emotional and coping experiences: (a) pretransition, (b) during the transition, and (c) posttransition. Five separate themes emerged, including descriptions of coping mechanisms, emotional hardship, lack of support, positive social support, and affirmative emotional experiences. The authors developed a model to describe the role of coping mechanisms and support experienced throughout the transition process. As participants continued through their transitions, emotional hardships lessened and they used facilitative coping mechanisms that in turn led to affirmative emotional experiences. The results of this study are indicative of the importance of guiding transgender individuals through facilitative coping experiences and providing social support throughout the transition process. Implications for counselors and for future research are discussed.

Cardoso da Silva et al., 2016

Before and After Sex Reassignment Surgery in Brazilian Male-to-Female Transsexual Individuals

Cardoso da Silva, D., Schwarz, K., Fontanari, A.M.V., Costa, A.B., Massuda, R., et al. (2016). WHOQOL-100 Before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. Journal of Sexual Medicine , 13 (6), 988-993.

Introduction: The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS). Aim: To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100. Methods: This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS. Main Outcome Measures: Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS. Results: The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results. Conclusion: The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence.

(Due to a citation error, this study was initially listed twice.)

Castellano et al., 2015

Castellano, E., Crespi, C., Dell’Aquila, R., Rosato, C., Catalano, V., et al. (2015). Quality of life and hormones after sex reassignment surgery. Journal of Endocrinological Investigation , 38 (12), 1373-1381.

Background: Transpeople often look for sex reassignment surgery (SRS) to improve their quality of life (QoL). The hormonal therapy has many positive effects before and after SRS. There are no studies about correlation between hormonal status and QoL after SRS. Aim: To gather information on QoL, quality of sexual life and body image in transpeople at least 2 years after SRS, to compare these results with a control group and to evaluate the relations between the chosen items and hormonal status. Subjects and methods: Data from 60 transsexuals and from 60 healthy matched controls were collected. Testosterone, estradiol, LH and World Health Organization Quality of Life (WHOQOL-100) self-reported questionnaire were evaluated. Student’s t test was applied to compare transsexuals and controls. Multiple regression model was applied to evaluate WHOQOL’s chosen items and LH. Results: The QoL and the quality of body image scores in transpeople were not statistically different from the matched control groups’ ones. In the sexual life subscale, transwomen’s scores were similar to biological women’s ones, whereas transmen’s scores were statistically lower than biological men’s ones (P = 0.003). The quality of sexual life scored statistically lower in transmen than in transwomen (P = 0.048). A significant inverse relationship between LH and body image and between LH and quality of sexual life was found. Conclusions: This study highlights general satisfaction after SRS. In particular, transpeople’s QoL turns out to be similar to Italian matched controls. LH resulted inversely correlated to body image and sexual life scores.

Colizzi, Costa, & Todarello, 2014

Transsexual patients' psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: results from a longitudinal study

Colizzi, M., Costa, R. & Todarello, O. (2014). Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study. Psychoneuroendocrinology , 39 , 65-73.

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients’ mental health.

Colizzi et al., 2013

Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style

Colizzi. M., Costa, R., Pace, V., & Todarello, O. (2013). Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. The Journal of Sexual Medicine , 10 (12), 3049–3058.

Introduction: Gender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic–pituitary–adrenal system dysregulation and subjective stress. Aim: The objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern. Methods: We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers. Main Outcome Measures: We used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self‐reported perceived stress and the Adult Attachment Interview to determine attachment styles. Results: At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P < 0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment. Conclusion: Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be.

Colton-Meier et al., 2011

The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals

Colton-Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay & Lesbian Mental Health , 15 (3), 281-299.

Hormonal interventions are an often-sought option for transgender individuals seeking to medically transition to an authentic gender. Current literature stresses that the effects and associated risks of hormone regimens should be monitored and well understood by health care providers (Feldman & Bockting, 2003). However, the positive psychological effects following hormone replacement therapy as a gender affirming treatment have not been adequately researched. This study examined the relationship of hormone replacement therapy, specifically testosterone, with various mental health outcomes in an Internet sample of more than 400 self-identified female-to-male transsexuals. Results of the study indicate that female-to-male transsexuals who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Testosterone use was not related to problems with drugs, alcohol, or suicidality. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.

Costantino et al., 2013

A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery

Costantino, A., Cerpolini, S., Alvisi, S., Morselli, P. G., Venturoli, S., & Meriggiola, M. C. (2013). A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. Journal of Sex & Marital Therapy , 39 (4), 321-335.

Testosterone administration in female-to-male transsexual subjects aims to develop and maintain the characteristics of the desired sex. Very little data exists on its effects on sexuality of female-to-male transsexuals. The aim of this study was to evaluate sexual function and mood of female-to-male transsexuals from their first visit, throughout testosterone administration and after sex reassignment surgery. Participants were 50 female-to-male transsexual subjects who completed questionnaires assessing sexual parameters and mood. The authors measured reproductive hormones and hematological parameters. The results suggest a positive effect of testosterone treatment on sexual function and mood in female-to-male transsexual subjects.

Davis and Meier, 2014

Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People

Davis, S. A. & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health , 26 (2), 113-128.

Objectives: This study examined the effects of testosterone treatment with or without chest reconstruction surgery (CRS) on mental health in female-to-male transgender people (FTMs). Methods: More than 200 FTMs completed a written survey including quantitative scales to measure symptoms of anxiety and depression, feelings of anger, and body dissatisfaction, as well as qualitative questions assessing shifts in sexuality after the initiation of testosterone. Fifty-seven percent of participants were taking testosterone and 40% had undergone CRS. Results: Cross-sectional analysis using a between-subjects multivariate analysis of variance showed that participants who were receiving testosterone endorsed fewer symptoms of anxiety and depression as well as less anger than the untreated group. Participants who had CRS in addition to testosterone reported less body dissatisfaction than both the testosterone-only or the untreated groups. Furthermore, participants who were injecting testosterone on a weekly basis showed significantly less anger compared with those injecting every other week. In qualitative reports, more than 50% of participants described increased sexual attraction to nontransgender men after taking testosterone. Conclusions: Results indicate that testosterone treatment in FTMs is associated with a positive effect on mental health on measures of depression, anxiety, and anger, while CRS appears to be more important for the alleviation of body dissatisfaction. The findings have particular relevance for counselors and health care providers serving FTM and gender-variant people considering medical gender transition.

De Cuypere et al., 2006

Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery

De Cuypere, G., Elaut, E., Heylens, G., Maele, G. V., Selvaggi, G., et al. (2006). Long-term follow-up: Psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies , 15 (2), 126-133.

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects’ initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Dhejne et al., 2014

An analysis of all applications for sex reassignment surgery in Sweden, 1960-2010: prevalence, incidence, and regrets

Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An analysis of all applications for sex reassignment surgery in sweden, 1960-2010: Prevalence, incidence, and regrets. Archives of Sexual Behavior , 43 (8), 1535-1545.

Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2 % regret rate for both sexes. There was a significant decline of regrets over the time period.

Eldh, Berg, & Gustafsson, 1997

Eldh, J., Berg, A., Gustafsson, M. (1997). Long-term follow up after sex reassignment surgery. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery , 27 (1), 39-45.

A long-term follow up of 136 patients operated on for sex reassignment was done to evaluate the surgical outcome. Social and psychological adjustments were also investigated by a questionnaire in 90 of these 136 patients. Optimal results of the operation are essential for a successful outcome. Personal and social instability before operation, unsuitable body build, and age over 30 years at operation correlated with unsatisfactory results. Adequate family and social support is important for postoperative functioning. Sex reassignment had no influence on the person’s ability to work.

Fisher et al., 2014

Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria

Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., et al. (2014). Cross‐sex hormonal treatment and body uneasiness in individuals with gender dysphoria. The Journal of Sexual Medicine , 11 (3), 709–719.

Introduction: Cross‐sex hormonal treatment (CHT) used for gender dysphoria (GD) could by itself affect well‐being without the use of genital surgery; however, to date, there is a paucity of studies investigating the effects of CHT alone. Aims: This study aimed to assess differences in body uneasiness and psychiatric symptoms between GD clients taking CHT and those not taking hormones (no CHT). A second aim was to assess whether length of CHT treatment and daily dose provided an explanation for levels of body uneasiness and psychiatric symptoms. Methods: A consecutive series of 125 subjects meeting the criteria for GD who not had genital reassignment surgery were considered. Main Outcome Measures: Subjects were asked to complete the Body Uneasiness Test (BUT) to explore different areas of body‐related psychopathology and the Symptom Checklist‐90 Revised (SCL‐90‐R) to measure psychological state. In addition, data on daily hormone dose and length of hormonal treatment (androgens, estrogens, and/or antiandrogens) were collected through an analysis of medical records. Results: Among the male‐to‐female (MtF) individuals, those using CHT reported less body uneasiness compared with individuals in the no‐CHT group. No significant differences were observed between CHT and no‐CHT groups in the female‐to‐male (FtM) sample. Also, no significant differences in SCL score were observed with regard to gender (MtF vs. FtM), hormone treatment (CHT vs. no‐CHT), or the interaction of these two variables. Moreover, a two‐step hierarchical regression showed that cumulative dose of estradiol (daily dose of estradiol times days of treatment) and cumulative dose of androgen blockers (daily dose of androgen blockers times days of treatment) predicted BUT score even after controlling for age, gender role, cosmetic surgery, and BMI. Conclusions: The differences observed between MtF and FtM individuals suggest that body‐related uneasiness associated with GD may be effectively diminished with the administration of CHT even without the use of genital surgery for MtF clients. A discussion is provided on the importance of controlling both length and daily dose of treatment for the most effective impact on body uneasiness.

Glynn et al., 2016

The role of gender affirmation in psychological well-being among transgender women

Glynn, T. R., Gamarel, K. E., Kahler, C. W., Iwamoto, M., Operario, D., & Nemoto, T. (2016). The role of gender affirmation in psychological well-being among transgender women. Psychology Of Sexual Orientation And Gender Diversity , 3 (3), 336-344.

High prevalence of psychological distress, including greater depression, lower self-esteem, and suicidal ideation, has been documented across numerous samples of transgender women and has been attributed to high rates of discrimination and violence. According to the gender affirmation framework (Sevelius, 2013), access to sources of gender-affirmative support can offset such negative psychological effects of social oppression. However, critical questions remain unanswered in regards to how and which aspects of gender affirmation are related to psychological well-being. The aims of this study were to investigate the associations among 3 discrete areas of gender affirmation (psychological, medical, and social) and participants’ reports of psychological well-being. A community sample of 573 transgender women with a history of sex work completed a 1-time self-report survey that assessed demographic characteristics, gender affirmation, and mental health outcomes. In multivariate models, we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem whereas no domains of affirmation were significantly associated with suicidal ideation. Findings support the need for accessible and affordable transitioning resources for transgender women to promote better quality of life among an already vulnerable population. However, transgender individuals should not be portrayed simplistically as objects of vulnerability, and research identifying mechanisms to promote wellness and thriving is necessary for future intervention development. As the gender affirmation framework posits, the personal experience of feeling affirmed as a transgender person results from individuals’ subjective perceptions of need along multiple dimensions of gender affirmation. Thus, personalized assessment of gender affirmation may be a useful component of counseling and service provision for transgender women.

Gomez-Gil et al., 2012

Hormone-treated transsexuals report less social distress, anxiety and depression

Gomez-Gil, E., Zubiaurre-Elorz, L., Esteva, I., Guillamon, A., Godas, T., Cruz Almaraz, M., Halperin, I., Salamero, M. (2012). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology , 37 (5), 662-670.

Introduction: The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals. Methods: We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety. Results: The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F = 4.362, p = .038; F = 14.589, p = .001; F = 9.523, p = .002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively). Conclusions: The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Gomez-Gil et al., 2014

Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery

Gómez-Gil, E., Zubiaurre-Elorza, L., de Antonio, E. D., Guillamon, A., & Salamero, M. (2014). Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery. Quality of Life Research , 23 (2), 669-676.

Purpose: To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL. Methods: A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire). Results: Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor. Conclusions: Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Gorin-Lazard et al., 2012

Is hormonal therapy associated with better quality of life in transsexuals? A cross-sectional study

Gorin‐Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Gebleux, S., Penochet, J., Pringuey, D., Albarel, F., Morange, I., Loundou, A., Berbis, J., Auquier, P., Lançon, C. and Bonierbale, M. (2012). Is hormonal therapy associated with better quality of life in transsexuals? A cross‐sectional study. The Journal of Sexual Medicine , 9 (2), 531–541.

Introduction: Although the impact of sex reassignment surgery on the self‐reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce. Aims: The objectives of this study were to assess the relationship between hormonal therapy and the self‐reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross‐sex hormone therapy as well as between transsexuals and the general population (French age‐ and sex‐matched controls). Methods: This study incorporated a cross‐sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM‐IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre‐sex reassignment surgery. Main Outcome Measure. QoL was assessed using the Short Form 36 (SF‐36). Results: The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty‐four (72.1%) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF‐36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals’ QoL, independently of hormonal status, did not differ from the French age‐ and sex‐matched controls except for two subscales of the SF‐36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls). Conclusion: The present study suggests a positive effect of hormone therapy on transsexuals’ QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.

Gorin-Lazard et al., 2013

Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals

Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Penochet, J. C., et al. (2013). Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. Journal of Nervous and Mental Disease , 201 (11), 996–1000.

Few studies have assessed the role of cross-sex hormones on psychological outcomes during the period of hormonal therapy preceding sex reassignment surgery in transsexuals. The objective of this study was to assess the relationship between hormonal therapy, self-esteem, depression, quality of life (QoL), and global functioning. This study incorporated a cross-sectional design. The inclusion criteria were diagnosis of gender identity disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and inclusion in a standardized sex reassignment procedure. The outcome measures were self-esteem (Social Self-Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning). Sixty-seven consecutive individuals agreed to participate. Seventy-three percent received hormonal therapy. Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater “psychological-like” dimensions of QoL. These findings should provide pertinent information for health care providers who consider this period as a crucial part of the global sex reassignment procedure.

Hess et al., 2014

Hess, J., Neto, R. R., Panic, L., Rübben, H., & Senf, W. (2014). Satisfaction with male-to-female gender reassignment surgery: Results of a retrospective analysis. Deutsches Ärzteblatt International , 111 (47), 795–801.

Background: The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery. Methods: 254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital’s Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction. Results: 119 (46.9%) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1–7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now. Conclusion: The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.

Heylens et al., 2014

Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder

Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., & De Cuypere, G. (2014). Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. The Journal of Sexual Medicine , 11 (1), 119–126.

Introduction: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. Aims: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. Methods: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist‐90 (SCL‐90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. Main Outcome Measures: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. Results: A difference in SCL‐90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL‐90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre‐ and postoperative assessments. Conclusions: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Imbimbo et al., 2009

A report from a single institute's 14-year experience in treatment of male-to-female transsexuals

Imbimbo, C., Verze, P., Palmieri, A., Longo, N., Fusco, F., Arcaniolo, D., & Mirone, V. (2009). A report from a single institute’s 14-year experience in treatment of male-to-female transsexuals. The Journal of Sexual Medicine , 6 (10), 2736–2745.

Introduction: Gender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion. Aim: The aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS. Methods: From January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire. Main Outcome Measures: The questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction. Results: Average age was 31 years old. Seventy-two percent had a high educational level, and 63% were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4% had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina’s esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets. Conclusions: Our patients’ high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up.

Johansson et al., 2010

Johansson, A., Sundbom, E., Höjerback, T., & Bodlund, O. (2010). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of Sexual Behavior , 39 (6), 1429-1437.

This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69%) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At follow-up, 32 patients had completed sex reassignment surgery, five were still in process, and five—following their own decision—had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5–15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years), and non-homosexually oriented (56 vs. 15%). In conclusion, almost all patients were satisfied with the sex reassignment; 86% were assessed by clinicians at follow-up as stable or improved in global functioning.

Keo-Meier et al., 2015

Keo-Meier, C. L., Herman, L. I., Reisner, S. L., Pardo, S. T., Sharp, C., & Babcock, J. C. (2015). Testosterone treatment and MMPI-2 improvement in transgender men: A prospective controlled study. Journal of Consulting and Clinical Psychology, 83 , 143-156.

Objective: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects. Method: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI–2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender × Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds. Results: Statistically significant changes in MMPI–2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity–Femininity scores (p < .01). Gender × Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05). Conclusions: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men.

Kraemer et al., 2008

Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology , 41 (2), 96-100.

Background: To achieve a detailed view of the body image of transsexual patients, an assessment of perception, attitudes and experiences about one’s own body is necessary. To date, research on the body image of transsexual patients has mostly covered body dissatisfaction with respect to body perception. Sampling and Methods: We investigated 23 preoperative (16 male-to-female and 7 female-to-male transsexual patients) and 22 postoperative (14 male-to-female and 8 female-to-male) transsexual patients using a validated psychological measure for body image variables. Results: We found that preoperative transsexual patients were insecure and felt unattractive because of concerns about their body image. However, postoperative transsexual patients scored high on attractiveness and self-confidence. Furthermore, postoperative transsexual patients showed low scores for insecurity and concerns about their body. Conclusions: Our results indicate an improvement of body image concerns for transsexual patients following standards of care for gender identity disorder. Follow-up studies are recommended to confirm the assumed positive outcome of standards of care on body image.

Landen et al., 1998

Landén, M., Wålinder, J., Hambert, G., & Lundström, B. (1998). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica , 97 (4), 284-289.

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient’s family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Lawrence, 2003

Lawrence, A. A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior , 32 (4), 299-315.

This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.

Lawrence, 2006

Lawrence, A. A. (2006). Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Archives of Sexual Behavior , 35 (6), 717-727.

This study examined preoperative preparations, complications, and physical and functional outcomes of male-to-female sex reassignment surgery (SRS), based on reports by 232 patients, all of whom underwent penile-inversion vaginoplasty and sensate clitoroplasty, performed by one surgeon using a consistent technique. Nearly all patients discontinued hormone therapy before SRS and most reported that doing so created no difficulties. Preoperative electrolysis to remove genital hair, undergone by most patients, was not associated with less serious vaginal hair problems. No patients reported rectal-vaginal fistula or deep-vein thrombosis and reports of other significant surgical complications were uncommon. One third of patients, however, reported urinary stream problems. No single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation. Frequency of achieving orgasm after SRS was not significantly associated with most general measures of satisfaction. Later years of surgery, reflecting greater surgeon experience, were not associated with lower prevalence rates for most complications or with better ratings for most physical and functional outcomes of SRS.

Lobato et al., 2006

Lobato M. I., Koff, W. J., Manenti, C., da Fonseca Seger, D., Salvador, J., et al. (2006). Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort. Archives of Sexual Behavior, 35(6) , 711–715.

This study examined the impact of sex reassignment surgery on the satisfaction with sexual experience, partnerships, and relationship with family members in a cohort of Brazilian transsexual patients. A group of 19 patients who received sex reassignment between 2000 and 2004 (18 male- to-female, 1 female-to-male) after a two-year evaluation by a multidisciplinary team, and who agreed to participate in the study, completed a written questionnaire. Mean age at entry into the program was 31.21 ± 8.57 years and mean schooling was 9.2 ± 1.4 years. None of the patients reported regret for having undergone the surgery. Sexual experience was considered to have improved by 83.3% of the patients, and became more frequent for 64.7% of the patients. For 83.3% of the patients, sex was considered to be pleasurable with the neovagina/neopenis. In addition, 64.7% reported that initiating and maintaining a relationship had become easier. The number of patients with a partner increased from 52.6% to 73.7%. Family relationships improved in 26.3% of the cases, whereas 73.7% of the patients did not report a difference. None of the patients reported worse relationships

Manieri et al., 2014

Medical Treatment of Subjects with Gender Identity Disorder: The Experience in an Italian Public Health Center

Manieri, C., Castellano, E., Crespi, C., Di Bisceglie, C., Dell’Aquila, C., et al. (2014). Medical treatment of subjects with gender identity disorder: The experience in an Italian public health center. International Journal Of Transgenderism , 15 (2), 53-65.

Hormonal treatment is the main element during the transition program for transpeople. The aim of this paper is to describe the care and treatment of subjects, highlighting both the endocrine-metabolic effects of the hormonal therapy and the quality of life during the first year of cross-sex therapy in an Italian gender team. We studied 83 subjects (56 male-to-female [MtF], 27 female-to-male [FtM]) with hematological and hormonal evaluations every 3 months during the first year of hormonal therapy. MtF persons were treated with 17βestradiol and antiandrogens (cyproterone acetate, spironolactone, dutasteride); FtM persons were treated with transdermal or intramuscular testosterone. The WHO Quality of Life questionnaire was administered at the beginning and 1 year later. Hormonal changes paralleled phenotype modifications with wide variability. Most of both MtF and FtM subjects reported a statistically significant improvement in body image (p < 0.05). In particular, MtF subjects reported a statistically significant improvement in the quality of their sexual life and in the general quality of life (p < 0.05) 1 year after treatment initiation. Cross-sex therapy seems to be free of major risks in healthy subjects under clinical supervision during the first year. Selected subjects show an optimal adaptation to hormone-induced neuropsychological modifications and satisfaction regarding general and sexual life.

Megeri and Khoosal, 2007

Megeri, D., & Khoosal, D. (2007). Anxiety and depression in males experiencing gender dysphoria. Sexual & Relationship Therapy , 22 (1), 77-81.

Objective: The aim of the study was to compare anxiety and depression scores for the first 40 male to female people experiencing gender dysphoria attending the Leicester Gender Identity Clinic using the same sample as control pre and post gender realignment surgery. Hypothesis: There is an improvement in the scores of anxiety and depression following gender realignment surgery among people with gender dysphoria (male to female – transwomen). Results: There was no significant change in anxiety and depression scores in people with gender dysphoria (male to female) pre- and post-operatively.

Nelson, Whallett, & Mcgregor, 2009

Nelson, L., Whallett, E., & McGregor, J. (2009). Transgender patient satisfaction following reduction mammaplasty. Journal of Plastic, Reconstructive & Aesthetic Surgery , 62 (3), 331-334.

Aim: To evaluate the outcome of reduction mammaplasty in female-to-male transgender patients. Method: A 5-year retrospective review was conducted on all female-to-male transgender patients who underwent reduction mammaplasty. A postal questionnaire was devised to assess patient satisfaction, surgical outcome and psychological morbidity. Results: Seventeen patients were identified. The senior author performed bilateral reduction mammaplasties and free nipple grafts in 16 patients and one patient had a Benelli technique reduction. Complications included two haematomas, one wound infection, one wound dehiscence and three patients had hypertrophic scars. Secondary surgery was performed in seven patients and included scar revision, nipple reduction/realignment, dog-ear correction and nipple tattooing. The mean follow-up period after surgery was 10 months (range 2–23 months). Twelve postal questionnaires were completed (response rate 70%). All respondents expressed satisfaction with their result and no regret. Seven patients had nipple sensation and nine patients were satisfied with nipple position. All patients thought their scars were reasonable and felt that surgery had improved their self-confidence and social interactions. Conclusion: Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

Newfield et al., 2006

Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender quality of life. Quality of Life Research , 15 (9), 1447-1457.

Objectives: We evaluated health-related quality of life in female-to-male (FTM) transgender individuals, using the Short-Form 36-Question Health Survey version 2 (SF-36v2). Methods: Using email, Internet bulletin boards, and postcards, we recruited individuals to an Internet site ( http://www.transurvey.org ), which contained a demographic survey and the SF36v2. We enrolled 446 FTM transgender and FTM transsexual participants, of which 384 were from the US. Results: Analysis of quality of life health concepts demonstrated statistically significant (p<0.0\) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (/?<0.01) than those who had not received hormone therapy. Conclusions: FTM transgender participants reported significantly reduced mental health-related quality of life and

Padula, Heru, & Campbell, 2016

Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis

Padula, W. V., Heru, S. & Campbell, J. D. (2016). Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: A cost-effectiveness analysis. Journal of General Internal Medicine , 31 ( 4), 394-401.

Background: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. Objective: To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. Design: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). Patients: U.S. transgender population starting before transitional therapy. Interventions: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. Main Measures: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. Key Results: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000–22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints —HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations. Conclusions: Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.

Parola et al., 2010

Study of quality of life for transsexuals after hormonal and surgical reassignment

Parola, N., Bonierbale, M., Lemaire, A., Aghababian, V., Michel, A., & Lançon, C. (2010). Study of quality of life for transsexuals after hormonal and surgical reassignment. Sexologies , 19 (1), 24-28.

Aim: The main objective of this work is to provide a more detailed assessment of the impact of surgical reassignment on the most important aspects of daily life for these patients. Our secondary objective was to establish the influence of various factors likely to have an impact on the quality of life (QoL), such as biological gender and the subject’s personality. Methods: A personality study was conducted using Eysenck Personality Inventory (EPI) so as to analyze two aspects of the personality (extraversion and neuroticism). Thirty-eight subjects who had undergone hormonal surgical reassignment were included in the study. Results: The results show that gender reassignment surgery improves the QoL for transsexuals in several different important areas: most are satisfied of their sexual reassignment (28/30), their social (21/30) and sexual QoL (25/30) are improved. However, there are differences between male-to-female (MtF) and female-to-male (FtM) transsexuals in terms of QoL: FtM have a better social, professional, friendly lifestyles than MtF. Finally, the results of this study did not evidence any influence by certain aspects of the personality, such as extraversion and neuroticism, on the QoL for reassigned subjects.

Pfäfflin, 1993

Pfäfflin, F. (1993). Regrets after sex reassignment surgery. Journal of Psychology & Human Sexuality , 5 (4), 69-85.

Using data draw from the follow-up literature covering the last 30 years, and the author’s clinical data on 295 men and women after SRS, an estimation of the number of patients who regretted the operations is made. Among female-to-male transsexuals after SRS, i.e., in men, no regrets were reported in the author’s sample, and in the literature they amount to less than 1%. Among male-to- female transsexuals after SRS, i.e., in women, regrets are reported in 1-1.5%. Poor differential diagnosis, failure to carry out the real-life- test, and poor surgical results seem to be the main reasons behind the regrets reported in the literature. According to three cases observed by the author in addition to personality traits the lack of proper care in treating the patients played a major role.

Pimenoff and Pfäfflin, 2011

Pimenoff, V., & Pfäfflin, F. (2011). Transsexualism: Treatment outcome of compliant and noncompliant patients. International Journal Of Transgenderism , 13 (1), 37-44.

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Rakic et al., 1996

Rakic, Z., Starcevic, V., Maric, J., & Kelin, K. (1996). The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes. Archives of Sexual Behavior , 25 (5), 515-525.

Several aspects of the quality of life after sex reassignment surgery in 32 transsexuals of both sexes (22 men, 10 women) were examined. The Belgrade Team for Gender Identity Disorders designed a standardized questionnaire for this purpose. The follow-up period after operation was from 6 months to 4 years, and four aspects of the quality of life were examined: attitude towards the patients’ own body, relationships with other people, sexual activity, and occupational functioning. In most transsexuals, the quality of life was improved after surgery inasmuch as these four aspects are concerned. Only a few transsexuals were not satisfied with their life after surgery.

Rehman et al., 1999

The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients

Rehman, J., Lazer, S., Benet, A. E., Schaefer, L. C., & Melman, A. (1999). The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Archives of Sexual Behavior , 28 (1), 71-89.

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (A.M.). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced post operatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Rotondi et al., 2011

Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians

Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Canadian Journal Of Community Mental Health , 30 (2), 135-155.

Although depression is understudied in transgender and transsexual communities, high prevalences have been reported. This paper presents original research from the Trans PULSE Project, an Ontario-wide, community-based initiative that surveyed 433 participants using respondent-driven sampling. The purpose of this analysis was to determine the prevalence of, and risk and protective factors for, depression among female-to-male (FTM) Ontarians (n = 207). We estimate that 66.4% of FTMs have symptomatology consistent with depression. In multivariable analyses, sexual satisfaction was a strong protective factor. Conversely, experiencing transphobia and being at the stage of planning but not having begun a medical transition (hormones and/or surgery) adversely affected mental health in FTMs.

Ruppin and Pfäfflin, 2015

Ruppin, U., & Pfäfflin, F. (2015). Long-term follow-up of adults with gender identity disorder. Archives of Sexual Behavior , 44 (5), 1321-1329.

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants’ gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10–24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Smith et al., 2005

Follow-up study of transsexuals after sex-reassignment surgery

Smith, Y. L. S., Van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. (2005). Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 35 (1), 89-99.

Background: We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome. Method: Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses. Results: After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes. Conclusions: The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.

van de Grift et al., 2017

Effects of Medical Interventions on Gender Dysphoria and Body Image: a Follow-up Study

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., Cuypere, G. D., Richter-Appelt, H., & Kreukels, B. P. (2017). Effects of medical interventions on gender dysphoria and body image. Psychosomatic Medicine , 79 (7), 815-823.

Objective: The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. Methods: Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). Results: At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. Conclusions: Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

Surgical Satisfaction, Quality of Life and Their Association After Gender Affirming Surgery: A Follow-up Study

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., & Kreukels, B. P. (2017). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. Journal of Sex & Marital Therapy , 44 (2), 138-148.

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR= 6.07). Satisfied respondents’ QoL scores were similar to reference values; dissatisfied or regretful respondents’ scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

Vujovic et al., 2009

Vujovic, S., Popovic, S., Sbutega-Milosevic, G., Djordjevic, M., & Gooren, L. (2009). Transsexualism in Serbia: A twenty-year follow-up study. The Journal of Sexual Medicine , 6 (4), 1018-1023.

Introduction: Gender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment. Aim: To describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia. Methods: Data, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively. Main Outcome Measures: Age at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated. Results: Applicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10% do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision. Conclusions: Although transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.

Weigert et al., 2013

Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals

Weigert, R., Frison, E., Sessiecq, Q., Al Mutairi, K., & Casoli, V. (2013). Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plastic and Reconstructive Surgery, 132 (6), 1421-1429.

Background: Satisfaction with breasts, sexual well-being, psychosocial well-being, and physical well-being are essential outcome factors following breast augmentation surgery in male-to-female transsexual patients. The aim of this study was to measure change in patient satisfaction with breasts and sexual, physical, and psychosocial well-being after breast augmentation in male-to-female transsexual patients. Methods: All consecutive male-to-female transsexual patients who underwent breast augmentation between 2008 and 2012 were asked to complete the BREAST-Q Augmentation module questionnaire before surgery, at 4 months, and later after surgery. A prospective cohort study was designed and postoperative scores were compared with baseline scores. Satisfaction with breasts and sexual, physical, and psychosocial outcomes assessment was based on the BREAST-Q. Results: Thirty-five male-to-female transsexual patients completed the questionnaires. BREAST-Q subscale median scores (satisfaction with breasts, +59 points; sexual well-being, +34 points; and psychosocial well-being, +48 points) improved significantly (p < 0.05) at 4 months postoperatively and later. No significant change was observed in physical well-being. Conclusions: In this prospective, noncomparative, cohort study, the current results suggest that the gains in breast satisfaction, psychosocial well-being, and sexual well-being after male-to-female transsexual patients undergo breast augmentation are statistically significant and clinically meaningful to the patient at 4 months after surgery and in the long term.

Weyers et al., 2009

Weyers, S., Elaut, E., De Sutter, P., Gerris, J., T’Sjoen, G., et al. (2009). Long-term assessment of the physical, mental, and sexual health among transsexual women. The Journal of Sexual Medicine , 6 (3), 752-760.

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Methods: Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited. Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

Below are 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to the 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being . Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

Barrett, 1998.

Barrett J. (1998). Psychological and social function before and after phalloplasty. The International Journal of Transgenderism , 2 (1), 1-8.

There are no quantitative assessments of the benefits of phalloplasty in a female transsexual population. The study addresses this question, comparing transsexuals accepted for such surgery with transsexuals after such surgery has been performed. A population of 23 transsexuals accepted for phalloplasty was compared to a population of 40 who had undergone such surgery between six and one hundred and sixty months previously. The General Health Questionnaire (GHQ), Symptom Checklist 90 (SCL-90), Bem Sex Role Inventory and Social Role Performance Schedule (SRPS) were employed. Additionally, a questionnaire assessing satisfaction with cosmetic appearance, sexual function, relationship and urinary function was used, along with a semi-structured interview quantifying alcohol, cigarette and drug usage, and current sexual practice. There were significant differences between the populations. The post operative group showed higher depression ratings on the depression subscale of the GHQ. The masculine pre-operative Bem scores were neutral post-operatively as feminine sub-scores increased. There was improved satisfaction with genital appearance post-operatively, but satisfaction with relationships fell, although to a non-significant extent. Most other changes were in the expected direction but did not achieve significance. Transsexuals accepted for phalloplasty have very good psychological health. Tendency to further improvement is the case after phalloplasty. Depression is commoner, however, and quality of relationships declines somewhat, perhaps in consequence. Surgeons might advise partners as well as patients of realistic expectations from such surgery.

Lindqvist et al., 2017

Quality of life improves early after gender reassignment surgery in transgender women.

Lindqvist, E. K., Sigurjonsson, H., Möllermark, C., Rinder, J., Farnebo, F., et al. (2017). Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery , 40 (3), 223-226.

Background: Few studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS). Methods: We performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Results: On most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined. Conclusions: To our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group. Level of evidence: Level III, therapeutic study.

Simonsen et al., 2016

Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality

Simonsen, R. K., Giraldi, A., Kristensen, E., & Hald, G. M. (2016). Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality. Nordic Journal Of Psychiatry , 70 (4), 241-247.

Background: There is a lack of long-term register-based follow-up studies of sex-reassigned individuals concerning mortality and psychiatric morbidity. Accordingly, the present study investigated both mortality and psychiatric morbidity using a sample of individuals with transsexualism which comprised 98% (n = 104) of all individuals in Denmark. Aims: (1) To investigate psychiatric morbidity before and after sex reassignment surgery (SRS) among Danish individuals who underwent SRS during the period of 1978–2010. (2) To investigate mortality among Danish individuals who underwent SRS during the period of 1978–2010.Method: Psychiatric morbidity and mortality were identified by data from the Danish Psychiatric Central Research Register and the Cause of Death Register through a retrospective register study of 104 sex-reassigned individuals. Results: Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant). A total of 6.7% of the sample were registered with psychiatric morbidity both before and after SRS. Significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth. Ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years. Conclusions: No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM) save for the total number of psychiatric diagnoses where FtM held a significantly higher number of psychiatric diagnoses overall. Despite the over-representation of psychiatric diagnoses both pre- and post-SRS the study found that only a relatively limited number of individuals had received diagnoses both prior to and after SRS. This suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.

Udeze, 2008

Udeze, B., Abdelmawla, N., Khoosal, D., & Terry, T. (2008). Psychological functions in male-to-female transsexual people before and after surgery. Sexual & Relationship Therapy , 23 (2), 141-145.

Patients with gender dysphoria (GD) suffer from a constant feeling of psychological discomfort related to their anatomical sex. Gender reassignment surgery (GRS) attempts to release this discomfort. The aim of this study was to compare the functioning of a cohort or patients with GD before and after GRS. We hypothesized that there would be an improvement in the scores of the self-administered SCL-90R following gender reassignment surgery among male-to-female people with gender dysphoria. We studied 40 patients with a DSM-IV diagnosis of Gender Identity Disorder (GID) who attended Leicester Gender Identity Clinic. We compared their functioning as measured by Symptom Check List-90R (SCL-90R) which was administered to 40 randomly selected male-to-female patients before and within six months after GRS using the same sample as control pre-and post-surgery. There was no significant change in the different sub-scales of the SCL-90R scores in patients with male-to-female GID pre- and within six months post-surgery. The results of the study showed that GRS had no significant effect on functioning as measured by SCL-90R within six months of surgery. Our study has the advantage of reducing inter-subject variability by using the same patients as their own control. This study may be limited by the duration of reassessment post-surgery. Further studies with larger sample size and using other psychosocial scales are needed to elucidate on the effectiveness of surgical intervention on psychosocial parameters in patients with GD.

Below are 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being. Click here to jump to the 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

American psychological, 2015.

Guidelines for psychological practice with transgender and gender nonconforming people. (2015). American Psychologist, 70 (9), 832-864.

In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.

Bockting et al., 2016

Adult development and quality of life of transgender and gender nonconforming people

Bockting, W., Coleman, E., Deutsch, M. B., Guillamon, A., Meyer, W., et al. (2016). Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology & Diabetes and Obesity , 23 (2), 188–197.

Purpose of review: Research on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research. Recent findings: Pervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and well-being. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. Although there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking. Summary: Greater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

Byne et al., 2012

Byne, W., Bradley, S.J., Coleman, E., et al. (2012). Report of the American Psychiatric Association task force on treatment of gender identity disorder. Archives of Sexual Behavior, 41 (4): 759–796.

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Carroll, 1999

Carroll, R. A. (1999). Outcomes of treatment for gender dysphoria. Journal of Sex Education and Therapy , 24 (3), 128–136.

This paper reviews the empirical research on the psychosocial outcomes of treatment for gender dysphoria. Recent research has highlighted the heterogeneity of transgendered experiences. There are four possible outcomes for patients who present with the dilemma of gender dysphoria: an unresolved outcome, acceptance of one’s given gender, engaging in a cross-gender role on a part-time basis, and making a full-time transition to the other gender role. Clinical work, but not empirical research, suggests that some individuals with gender dysphoria may come to accept their given gender role through psychological treatment. Many individuals find that it is psychologically sufficient to express the transgendered part of themselves through such activities as cross-dressing or gender blending. The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive. Predictors of a good outcome include good pre-reassignment psychological adjustment, family support, at least 1 year of living in the desired role, consistent use of hormones, psychological treatment, and good surgical outcomes. The outcome literature provides strong support for adherence to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association. Implications to be drawn from this research include an appreciation of the diversity of transgendered experience, the need for more research on non-reassignment resolutions to gender dysphoria, and the importance of assisting the transgendered individual to identify the resolution that best suits him or her.

Cohen-Kettenis and Gooren, 1999

Homophobic teasing, psychological outcomes, and sexual orientation among high school students: What influence do parents and schools have.

Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology, diagnosis and treatment. Journal of Psychosomatic Research , 46 (4), 315-333.

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Coleman et al., 2012

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism , 13 (4), 165-232.

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Committee on Health Care for Underserved, 2011

Committee Opinion No. 512: Health Care for Transgender Individuals. (2011). Obstetrics & Gynecology , 118 (6), 1454–1458.

Transgender individuals face harassment, discrimination, and rejection within our society. Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population. Although the care for these patients is often managed by a specialty team, obstetrician–gynecologists should be prepared to assist or refer transgender individuals with routine treatment and screening as well as hormonal and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity and urges public and private health insurance plans to cover the treatment of gender identity disorder.

Costa and Colizzi, 2016

Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatric Disease and Treatment , 12 , 1953-1966.

Cross-sex hormonal treatment represents a main aspect of gender dysphoria health care pathway. However, it is still debated whether this intervention translates into a better mental well-being for the individual and which mechanisms may underlie this association. Although sex reassignment surgery has been the subject of extensive investigation, few studies have specifically focused on hormonal treatment in recent years. Here, we systematically review all studies examining the effect of cross-sex hormonal treatment on mental health and well-being in gender dysphoria. Research tends to support the evidence that hormone therapy reduces symptoms of anxiety and dissociation, lowering perceived and social distress and improving quality of life and self-esteem in both male-to-female and female-to-male individuals. Instead, compared to female-to-male individuals, hormone-treated male-to-female individuals seem to benefit more in terms of a reduction in their body uneasiness and personality-related psychopathology and an amelioration of their emotional functioning. Less consistent findings support an association between hormonal treatment and other mental health-related dimensions. In particular, depression, global psychopathology, and psychosocial functioning difficulties appear to reduce only in some studies, while others do not suggest any improvement in these domains. Results from longitudinal studies support more consistently the association between hormonal treatment and improved mental health. On the contrary, a number of cross-sectional studies do not support this evidence. This review provides possible biological explanation vs psychological explanation (direct effect vs indirect effect) for the hormonal treatment-induced better mental well-being. In conclusion, this review indicates that gender dysphoria-related mental distress may benefit from hormonal treatment intervention, suggesting a transient reaction to the nonsatisfaction connected to the incongruent body image rather than a stable psychiatric comorbidity. In this perspective, timely hormonal treatment intervention represents a crucial issue in gender dysphoria individuals’ mental health-related outcome.

Dhejne et al., 2016

Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review Of Psychiatry , 28 (1), 44-57.

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Gijs and Brewaeys, 2007

Gijs, L., & Brewaeys, A. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges. Annual Review of Sex Research , 18 (1), 178-224.

In 1990 Green and Fleming concluded that sex reassignment surgery (SRS) is an effective treatment for transsexuality because it reduced gender dysphoria drastically. Since 1990, many new outcome studies have been published, raising the question as to whether the conclusion of Green and Fleming still holds. After describing terminological and conceptual developments related to the treatment of gender identity disorder (GID), follow-up studies, including both adults and adolescents, of the outcomes of SRS are reviewed. Special attention is paid to the effects of SRS on gender dysphoria, sexuality, and regret. Despite methodological shortcomings of many of the studies, we conclude that SRS is an effective treatment for transsexualism and the only treatment that has been evaluated empirically with large clinical case series.

Gooren, 2011

Clinical practice. Care of transsexual persons

Gooren, L. J. (2011). Care of transsexual persons. New England Journal of Medicine , 364 (13), 1251–1257.

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise? A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise?

Hembree et al., 2009

Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline

Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W., et al. (2009). Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 94 (9), 3132–3154.

Objective: The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. Consensus Process: Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. Conclusions: Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person’s genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person’s desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons. Endocrine treatment of transsexual persons should include suppression of endogenous sex hormones, physiologic levels of gender-appropriate sex hormones, and suppression of puberty in adolescents (Tanner stage 2).

Michel et al., 2002

Michel, A., Ansseau, M., Legros, J., Pitchot, W., & Mormont, C. (2002). The transsexual: What about the future? European Psychiatry , 17 (6), 353-362.

Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.

Murad et al., 2010

Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes

Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology , 72 (2), 214-231.

Objective: To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self‐reported psychosocial outcomes. Methods: We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random‐effects meta‐analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between‐study heterogeneity not attributable to chance using the I2 statistic. Results: We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male‐to‐female, 801 female‐to‐male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). Conclusions: Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

Reisner et al., 2016

Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., et al. (2016). Global health burden and needs of transgender populations: A review. The Lancet , 388 (10042), 412-436.

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Schmidt and Levine, 2015

Schmidt, L., & Levine, R. (2015). Psychological Outcomes and Reproductive Issues Among Gender Dysphoric Individuals. Endocrinology and Metabolism Clinics of North America , 44 (4), 773-785.

Gender dysphoria is a condition in which a person experiences discrepancy between the natal anatomic sex and the gender he or she identifies with, resulting in internal distress and a desire to live as the preferred gender. There is increasing demand for treatment, which includes suppression of puberty, cross-sex hormone therapy, and sex reassignment surgery. This article reviews longitudinal outcome data evaluating psychological well-being and quality of life among transgender individuals who have undergone cross-sex hormone treatment or sex reassignment surgery. Proposed methodologies for diagnosis and initiation of treatment are discussed, and the effects of cross-sex hormones and sex reassignment surgery on future reproductive potential.

White Hughto and Reisner, 2016

A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals

White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health , 1 (1), 21–31.

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time. Data Sources: MEDLINE, PsycINFO, and PubMed were searched for relevant studies from inception to November 2014. Reference lists of included studies were hand searched. Results: Three uncontrolled prospective cohort studies, enrolling 247 transgender adults (180 male-to-female [MTF], 67 female-to-male [FTM]) initiating hormone therapy for the treatment of gender identity disorder (prior diagnostic term for gender dysphoria), were identified. The studies measured exposure to hormone therapy and subsequent changes in mental health (e.g., depression, anxiety) and quality of life outcomes at follow-up. Two studies showed a significant improvement in psychological functioning at 3–6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy. Conclusions: Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning. Prospective controlled trials are needed to investigate the effects of hormone therapy on the mental health of transgender people.

ORIGINAL RESEARCH article

Improvement in gender and transgender knowledge in university students through the creative factory methodology.

$\r\nMaitane Picaza Gorrotxategi$

1 Department of Didactics and School Organization, Universidad del País Vasco/Euskal Herriko Unibertsitatea UPV/EHU, University of the Basque Country UPV/EHU, Leioa, Spain
2 Department of Developmental and Educational Psychology, Universidad del País Vasco/Euskal Herriko Unibertsitatea UPV/EHU, University of the Basque Country UPV/EHU, Leioa, Spain
3 Counseling, Leadership, and Special Education, Missouri State University, Springfield, MO, United States

In Spain, Social Educators, similar to both social workers and educators in the United States, help coordinate social change through educational interventions and mobilization of social groups to benefit marginalized people and overall societal welfare. They are trained to work with diverse populations, and it is important that they have awareness and training on gender and transgender issues given the extensive discrimination that transgender people endue. Research has begun to identify the important role that knowledge and attitudes of health and educational professionals may play in providing a supportive, healing context to combat the harmful effects of this discrimination and how educational trainings may foster improved knowledge and attitudes in helping professions. This study describes a program to improve knowledge and positive attitudes toward gender and especially transgender people in university students who study Social Education. The researchers measured knowledge and attitudes toward gender and transgender people issues of 64 students before and after receiving a 4-month interactive training. They used the Short Form of the Genderism and Transphobia Scale, a 12-item scale of transphobia and gender ideology variables. The researchers also asked participants about their knowledge of gender and transgender issues before and after training. The methodological experience “Creative Factory” was employed as an interactive training program. The main goal of this methodology is to enable students in a formative context to analyze social realities to generate discussion and innovate ideas to design successful practices. After 4 months of training with a weekly session on gender and transgender learning, students showed improvements in knowledge and attitudes toward both gender and transgender people. Specifically, students demonstrated more knowledge about gender and transgender issues and more positive attitudes toward transgender people. The study demonstrates that training in gender education using the Creative Factory methodology improved knowledge and attitudes in students.

Introduction

The European Union (EU) states in Article 1 of the Charter of Fundamental Rights (2011) that human dignity must be respected and protected. Article 21 of the same Charter censors discrimination on the basis of gender and sexual orientation and in the same year resolution 17/19 recognizes the rights of the LGBT community for the first time including lesbian, gay, bisexual, and transgender people ( DePalma and Cebreiro, 2018 ). Transgender is a general term in which people living their daily lives feel and live as the opposite gender to the one associated with the sex assigned to them at birth ( American Psychiatric Association [APA], 2019 ). The term “transgender” refers to a wide range of social identities and gender presentations ( Billard, 2018 ). In a study conducted in the United States, transgender people were classified into three groups: (1) people who were assigned as men at birth who felt they were women, (2) people who were assigned as women at birth who felt they were men, and (3) those who did not identify as men or women ( Factor and Rothblum, 2008 ). In the last decade in particular, there is growing evidence that, in fact, there is a considerable group of people who do not identify as trans binaries ( Motmans et al., 2019 ).

Transgender people can be subject to severe violence though virtually all are subject to significant and harmful microaggressions and transphobic prejudice ( Grant et al., 2011 ). Transphobia refers to negative beliefs and attitudes about transgender people, including aversion and irrational fear of masculine women, feminine men, transvestites, transgender, or transsexuals ( Hill and Willoughby, 2005 ). The transgender group has historically been a marginalized group, and although today transgender people are more accepted by society, many health and mental health professionals (physicians, psychologists, social educators) either do not have knowledge or positive attitudes and do not believe that they are qualified to provide care services to transgender people and therefore avoid doing so ( Kanamori and Cornelius-White, 2016 , 2017 ). There is some evidence that gender expression, perhaps more so than mere sexual orientation or gender identity, may be a factor in the prejudice people experience. While transprejudice is clearly higher among males than females and heterosexuals than LGBT people, there is also evidence that transgender people may be marginalized within the LGBT community when they violate traditional gender roles ( Salvati et al., 2018a , b ).

It is therefore important for helping professionals who are in contact with transgender people to gain successful educational and training experiences to become familiar with the trans history and culture and demonstrate better interaction patterns with transgender people. It is crucial to design and test interventions with such professionals, preferably early in their training such as during university.

Literature Review

Transphobic attitudes in general.

There is a plethora of research that has been done in the context of gender studies has been on research on sexism and homophobia. And although there are more and more studies that have been conducted on the prejudices that exist against people with transgender identities (e.g., Grant et al., 2011 ; Morison et al., 2018 ), comprehensive studies targeting the general transgender population are still lacking ( Scandurra et al., 2019 ). Likewise, there is also budding body of research investigating in particular the attitudes of helping professionals toward transgender persons (e.g., Kanamori et al., 2017 ; Stryker et al., 2019 ). While most of these studies are conducted with English-speaking samples, more research is needed with Spanish-speaking samples because they are not many (e.g., Carrera-Fernández et al., 2013 ) and none specially concerning knowledge and attitudes toward transgender persons within the ranks of social educators.

In a general population study of attitudes toward transgender people with 668 people, the results showed that a majority supported the possibility of transsexuals undergoing sex reassignment; however, 63% thought that the individual should bear the corresponding costs. In addition, a majority supported the right of transgender people to marry in their new sex and their right to work with children. The right of transgender people to adopt and raise children was supported by 43%, while 41% opposed it. The results indicated that those who believe that transsexuality is caused by biological factors had a less restrictive view of transsexuality than people who carry out a psychological view. Men and the older age group were found to have a more restrictive view of these issues than women and the younger age group ( Landén and Innala, 2000 ). This finding has also been found in other studies, where higher scores have been found in men than in women in terms of transphobia ( Nagoshi et al., 2008 ; Norton and Herek, 2013 ; Elischberger et al., 2016 ).

As an example of a study concerned with family relations and transphobia, Factor and Rothblum (2008) compared transgender people to their non-transgender siblings, and found that groups of transgender people experienced significantly less social support from their family than their non-transgender siblings. Transgender people also experienced more harassment and discrimination than their non-transgender brothers and sisters.

Another study by Lombardi et al. (2001) investigated the prevalence of transgender people who had experienced violence and discrimination. In their study they found that 60% of the respondents reported being victims of harassment by strangers on the street, verbal abuse, assault with a weapon and/or sexual assault. More than one-third (37%) of respondents also reported being disciplined at work, being degraded or treated unfairly, being fired and, consequently, experiencing economic problems ( Hill and Willoughby, 2005 ).

Although there is evidence that transgender people receive negative attitudes and transphobia from different groups, there are populations in which studies of attitudes toward transgender people demonstrate positive attitudes. Studies with health professionals and feminist communities show that these are populations with generally more positive attitudes toward transgender people ( Franzini and Casinelli, 1986 ; Kendel et al., 1997 ).

A study by Kanamori and Cornelius-White (2016) showed results consistent with the studies mentioned so far. In their study they found that health professionals in general maintain generally favorable attitudes toward transgender people. The study also found gender differences in attitudes consistent with many previous findings, finding that women showed more accepted attitudes toward transgender people than men.

Context of Transphobia in Spain for Educational Interventions

Given the need for studies with Spanish-speaking populations and the site of this study in Spain, this section will review the context that have been carried out on transphobia toward those that identify as transexual thanks to different contributions from activism and academia in this region ( Platero, 2014 ; Platero and Ortega, 2017 ).

Within the educational framework, different studies confirm the lack of attention to the issue, even though it is an issue that matters to different collectives that work with transgender people. For example, in medicine, where the framework for the interpretation of transsexuality comes from, the National Centre for LGBT Health Education offers educational programmes, resources and consultations to health care organizations with the aim of optimizing quality and cost-effective medical care for lesbian, gay, bisexual, and transgender (LGBT) people ( National LGBT Health Education Center, 2019 ).

Another organization for the visibility of transsexual minors is the appearance of the Association of Families of Transsexual Minors, Chrysallis , which is fighting for society, health and schools to meet the needs of transsexual children on an equal footing with cisexual children. To this end, they have made a list of about seventy schools they call transfriendly to facilitate the path of minors. Among the educational needs of the minors the association points out the essential “The training of all personnel related to the educational process, teachers, counselors, psychologists, assistants, social workers and management teams, as well as the training of students” ( Gavilán, 2015 , p. 85).

These examples reflect current social change in the interpretation of gender and sexuality. However, much remains to be done for these people to freely develop their identities. Various researches and studies indicate that, in the field of formal education, there are no training programs, and gender diversity is an issue that is not contemplated when different studies detect the need to work with students. For example, the European Union Agency for Fundamental Rigths [FRA], 2013 ), produced the largest set of empirical information with the LGBT collective to date with 93,000 people over 18 years of age in the EU, where its highlighted that members of this community can not be themselves in their daily lives. The results showed the following data: 47% of respondents had felt discriminated against or harassed because of their sexual orientation; more than 80% remembered negative comments or acts of bullying in the school environment and 67% of respondents stated that they hid their sexual orientation in the school stage.

In Spain, homophobic bullying has always been present in schools. INJUVE (2011) stressed that the homophobic collective imposes its law in classrooms in the face of the passivity of other students and teachers. In this line, some authors highlight the importance of the role of the observer as a facilitator of abuse ( Gini, 2006 ; Byers, 2013 ). A little later, in 2012/13, the Education Commission of the Lesbian, Gay, Transsexual and Bisexual Collective of Madrid (COGAM) together with the State Federation of Lesbians, Gays, Transsexuals and Bisexuals (FELGTB) carried out a study on sexual diversity in the classrooms where the results showed that of 653 children under 25 years of age who acknowledged having suffered bullying because of sexual orientation, 43% had come to devise suicide highlighting the failure of the school system ( DePalma and Cebreiro, 2018 ). Against this backdrop, Pichardo and Puche (2019) decide to focus on the attitude and practices of teachers in the face of sexual diversity. The results show that nursery, primary and secondary school teachers think that not being heterosexual or skipping gender traits or traits related to appearance are the reasons that generate the most insults or rejection. As we have read in the previous point, gender is also a variable where men are more likely to insult and less likely to ask for help and women are more likely to face issues of diversity and coexistence in the classroom. Finally, there is a constant demand for training on the part of the actors involved, both for teachers and students, since both groups are victims of discrimination (insults, mockery, exclusion) due to their personal characteristics ( Pichardo and Puche, 2019 ).

In this path of discrimination prior to the university stage, schools do not guarantee measures against the stigmatization and marginalization of these people where the educational dimension of heterosexual and patriarchal norms continues ( Elipe et al., 2017 ; Alegre, 2018 ). In the universities the panorama is not better either, the forms of identity and the new considerations associated to the inclusion of sexual diversity continue being a pending subject due to the strong cultural roots and the gender binarism. In addition, the concept of university is historical and maintains its essence, its raison d’être transcends all time, place or social circumstance without reforms prevailing ( Medina, 2005 ). Proof of this is that despite the fact that different media such as literature, cinema, plastic and audiovisual arts or advertising have introduced transsexual experiences in the educational sphere, the same does not happen in the academic sphere where there is a generalized misinformation about the LGBT+ community ( Castro and Ramos, 2019 ). Basque (Ley 09/2019, 2012), of 29 June 1 (Spain), includes in its articles 16 and 17 the obligation to incorporate methods, curricula and educational resources that serve to increase understanding and respect for the diversity of gender identities by dictating actions in matters of transsexuality. However, this law only works for basic education reflecting university absence.

Faced with this panorama, the university responds to heternormativity that is structured in a dichotomous system of male-fall-masculine and female-vulva-feminine. Therefore, LGBT people continue to be constructed as minorities respecting a community of equals made up of heterosexual people. This means that they are conceptualized from the discourse of otherness and from a hegemonic and heteronormative position. What generates that the educational intervention reproduces discourses that consider these people as deficit, limiting them in agency ( Galaz et al., 2016 ).

Faced with this situation, trans people exclude themselves, when choosing university studies they opt for training spaces perceived as safer and more respectful such as careers related to art, feminized (teaching or nursing) and humanities studies and related to social change also attracts them. However, more masculinized careers such as engineering or scientific-technical ones perceive them as less desirable. Despite the fact that in some universities there are associations of LGBT students, in general, the university is created as an androcentric and eurocentric space that strips itself of affectivity and focuses on science. Thus, the university has become a space full of physical, bureaucratic and symbolic barriers for LGBT people ( Pichardo and Puche, 2019 ).

The Creative Factory Intervention

For several years, the El Observatorio del Tercer Sector de Bizkaia (OTSB) ( Fundación EDE, 2016 ) has been developing the creative factory (CF) methodology as an educational intervention that generates reflections and innovative solutions to significant social problems and which aims to generate interaction between different agents. This proposal was born from the meeting of people and collectives working for social transformation from multiple fields, such as that of unaccompanied immigrants, people in processes of exclusion and with severe mental illness, mistreatment among peers or the response to violent behavior in adolescents, among others. In this way, students reflect from the critical (social, political, systemic) to foster creativity in order to respond to the integral development of the personality and to ensure that the educational institution is not content with merely reproducing the social system, but fulfils its function of transforming reality and that future professionals can develop alternative strategies to respond to social demands ( Rodrigo and Rodrigo, 2012 ). In addition, making use of creativity, professionals are able to adapt to new changing contexts and can contribute significantly to society ( Goñi, 2000 ; Chacón and Moncada, 2006 ). A recent study studying the creativity of university students concludes that students show greater creativity after having fostered it in class ( Caballero et al., 2019 ).

The CF methodology has been applied since the 2011/2012 academic year in the subject of General Didactics. We have based and been inspired by the process carried out by Alonso and Arandia (2014) but adapting it to the current group and making modifications. On this occasion, we introduce a growing topic relating to transsexual persons, adapting the methodology to the needs of the students after evaluation (2018/2019) for continuous improvement. Although the subject of transgender people has been introduced throughout the continuous assessment, the methodology of the CF is carried out through training sessions consist three seminars. That is to say, in order to deepen the theme and offer more formation, the CF process is accompanied by different interventions and educational activities throughout the 4-month period (September–December).

Objective and Hypothesis

Social educators work in many areas, with different vulnerable populations, including transgender populations. For this reason, the importance of training these professionals so that they can act and intervene in educational spaces as well as in family, work and community spaces is highlighted ( Parcerisa-Aran and Forés, 2003 ; Bas-Peña et al., 2014 ).

It is therefore important to assess the level of knowledge on gender and transgender issues in Social Education students and to design educational models that train students in these issues. In addition, it is also important to know the attitudes that they have toward transgender people since many times negative attitudes or concrete stereotypes are given from ignorance. Education is one of the basic tools for students to get to know this group and improve their knowledge and attitudes.

The main objectives of this study were, on the one hand, to measure the attitudes of social education students toward gender and transgender people, and on the other hand, to value the knowledge about transgender people in these students. And finally, to measure the changes in attitudes and knowledge after an education program in transgender people based on the creative factory methodology.

Hypotheses suggest that Social Education students would have positive attitudes toward gender and transgender people prior to taking the course. Since students do not receive much information on gender and transgender issues during their university studies, in terms of knowledge, it is expected that students will not have much knowledge on the subject of transgender before taking the transgender training course. As other studies have shown, women are expected to have better attitudes than men toward transgender people. Finally, thanks to the creative factory methodology, improvements are expected in both knowledge and attitudes toward gender and transgender people.

Materials and Methods

Participants.

The sample was taken from second-year Social Education degree students in the Public University of the Basque Country (Leioa, Spain). The researchers offered them voluntary participation in this study. 64 people participated in the study. The average age of the subjects was 20.23 years. 81% (52 people) of the participants were women, 17% (11 people) were men and 2% (1 person) was not identified as either men or women.

All the students participated on a voluntary basis, received information about the procedure of the investigation and gave their consent before participating in the study. Therefore, the procedure followed is approved by the Ethics Committee respecting the Helsinki Declaration of the World Medical Association.

Measures and Instruments

The short version of the gender and transphobia scale.

As Billard (2018) says, so far, there are six published scales for measuring attitudes toward transgender people: the Gender and Transphobia Scale (GTS; Hill and Willoughby, 2005 ), Transphobia Scale (TS; Nagoshi et al., 2008 ), Transgender Attitudes Scale (ATTI; Walch et al., 2012 ), Transgender Attitudes and Beliefs Scale (TABS; Kanamori et al., 2017 ), Transgender Prejudice Scale ( Case and Stewart, 2013 ) and Transprejudice Scale (for transgender women; Winter et al., 2009 ).

The Gender and Transphobia scale is a scale developed and validated in Canada (GTS; Hill and Willoughby, 2005 ) and analyses negative attitudes toward trans people, including transsexuals, transgender, and transvestites. It assesses the cognitive (gender), affective (transphobia) and behavioral (gender attack) of the co-components mentioned. It is a scale that has been translated and validated in several cultures.

The scale used in this study is the short version of the GTS was validated in Spanish with a stable factor structure and adequate reliability ( Carrera-Fernández et al., 2013 ). The brevity of the instrument saves time and increases the effectiveness of the evaluation processes. It is a test with good psychometric properties. The Cronbach’s alpha of their corresponding subscale indicated good psychometric properties. The scale showed good reliability, with a α = 0.80 for Gender Bashing and a α = 0.83 for Transphobia = Genderism ( Carrera-Fernández et al., 2013 ).

The scale is a 12-item scale that measures the variables of Gender Bashing, transphobia and genderism. The genderism is a belief system based on a heteronormative social model. Genderism devalues people who do not adjust to their gender roles or whose sex is not consistent with their gender. The transphobia is the attitudinal component and this includes negative feelings, aversion and fear of people who transgress the rigid two-gender model. Gender bashing is the act of victimizing a person emotionally, physically, sexually, or verbally because they are transgender. It is the behavioral component of sexism ( Carrera-Fernández et al., 2013 ).

The first six items of the short version of the GTS measures gender bashing and the last six transphobia and genderism. The answers are answered on a scale from 1 to 7 with the following values: 1 is strongly agree, 2 agree, 3 somewhat agree, 4 neutral, 5 somewhat disagree, 6 disagree and 7 Strongly disagree. Lower scores indicate a higher level of transphobic attitudes. The lowest score that can be obtained in these two factors would be a 7, indicating high levels of gender bashing and transphobia/genderism. The highest score that can be obtained in these two factors would be a 42, indicating absence of gender bashing and transphobia/genderism.

Scale to Measure Transgender Knowledge and Other Variables

For clarity and ease of administration, a single item measure employing Llikert scale of 1 to 10 was used to self-assess students’ knowledge of transgender people. Students had to evaluate their knowledge about transgender people: 1 being a complete lack of knowledge about the subject, and a 10 an optimal knowledge about the subject. The item was: my level of knowledge about what it means to be a transgender person is. The Likert scale places each individual at a particular point of knowledge. This scale is used to help the respondent assess his or her knowledge about the topic being asked. It allows us to measure the degree of knowledge that the respondent considers to have regarding a specific topic ( Ospina et al., 2005 ). Other variables collected were the age and gender of the students answering the questionnaire. It was also asked if they personally know any people who are transgender.

The first step was to secure permission from the university ethics committee to carry out this research. The project took place in a Spanish University with a World ranking in the top 500 universities within the undergraduate program of Social Education, which is composed of seven modules. Specifically, we are located in the subject of General Didactics belonging to the third module called Foundation of Educational Processes, which is taught in the first 4-month period of the second-year (2019/2020).

On the first day of class the students were informed about the study, and the people who decided to voluntarily participate in the study completed the pre-tests using the google forms platform. The questionnaires answered by the students were anonymous and had to include a code in order to identify the relationship between the questionnaires carried out before and after the educational intervention.

After the training they retook the measures again.

Data Analysis

The data of the participants were collected through google forms. To begin with, descriptive analyses were carried out for sociodemographic data, transgender knowledge, and Short Version of the GTS results. Paired t -test for related samples were calculated to compare the means between the test and retests in the variables of knowledge about transgenderism, and the gender bashing and transphobia/genderism factors of the GTS. t -tests were also performed for independent samples to see differences in Short version Gender and Transphobia Scale questionnaire factors between men and women. To analyze the data we used the program R-comander program and the results were reflected in tables.

Table 1 shows different descriptive variables of the sample, including maximums, minimums, means, and number of people and percentages of men, women and non-binary persons among the participants. The data show that the average age of the participants was 20.23 years and that most of the participants were women (81%).

Table 1. Age, gender, knowledge of any transgender person and knowledge of transgender issues of the study participants.

Knowledge about transgender issues is divided between groups that have scored less than 3, from 3 to 7, and more than 8 on a scale of 1 to 10. Where 1 would be the minimum knowledge about transgender topics, and 10 would be the optimal knowledge about transgender topics. Finally Table 1 includes the number of people and the percentage of people who had close relationships with transgender people, had acquaintances (not close relationships), and those who did not know transgender people. Most of the participants knew a transgendered person, although not necessarily (48%), and knowledge about transgender people was medium in most participants (61%).

Table 2 shows the comparison of means of knowledge about transgender people, gender bashing, and transphobia/genderism of the Short version Gender and Transphobia Scale between the test and the retest according to the t -test for related samples. The data show that there was a statistically significant improvement in knowledge about transgender. In the gender bashing and transphobia dimensions there were improvements although not significant.

Table 2. t -test for comparison knowledge about transgender people, gender bashing, and transphobia/genderism before and after training.

The mean comparisons shown in Table 3 were made between people who defined themselves as women or men. The differences between men and women in gender bashing were significant, with men having more gender bashing. There were no significant differences in transphobia. There was one person who did not define himself as either a man or a woman. But being only one is not representative to make a comparison of means between different genders. Therefore we will describe below the characteristics of this person. The scores in gender bashing was 42 and in transphobia 42 being the highest scores that can be taken on this scale and representing a very low level of both factors in this person.

Table 3. t -test for the comparison of independent means between men and women of the factors of gender bashing and transphobia/gender.

The descriptive data show the characteristic data of the students of Social Education where the average age is around 20 years old and the great majority of people are women. There was only one person who was not considered binary (neither male nor female).

Throughout the study, the relevance of making the reality of transgender people known has been justified in order to put an end to discriminatory attitudes and behaviors. Moreover, in social education professionals whose socio-educational work promotes the achievement of social change ( Parcerisa-Aran and Forés, 2003 ; Bas-Peña et al., 2014 ). The following is a review of the results found and the explanations that justify these results with the review of the scientific literature.

The first objective of the study was to explore the level of knowledge that students of the social education degree perceive to have toward what it means to be a transgender person. In this research, only 34% believe they have optimal knowledge. Therefore, the hypothesis is fulfilled that the students would not have much knowledge about this subject before having received specific training. The previous evidence showed the lack of information about LGBT+ collectives in the academic field ( Castro and Ramos, 2019 ). As well as professionals in contact with transgender people, with a perception of positive attitudes toward them, they did not feel qualified to respond to their needs due to the lack of training. Other research stated that trans people when choosing university studies could be inclined toward degrees related to social change or the humanities, perceiving them as more respectful and, therefore, safe environments ( Pichardo and Puche, 2019 ). In our study, dealing with a humanities degree, it has been found that only 25% of the participants say they know a transgender person closely, while 27% say they do not know any transgender person. This underlines the importance of increasing knowledge about this group even in those professions in which there is a greater sensitivity to work with disadvantaged groups ( Gavilán, 2015 ).

Several studies have found that transgender people experience violence and discrimination ( Lombardi et al., 2001 ; Hill and Willoughby, 2005 ). Fortunately, there are populations such as health professionals and feminist communities that have positive attitudes toward transgender people ( Franzini and Casinelli, 1986 ; Kendel et al., 1997 ). As has been observed in this study, social educators are also a population with positive attitudes toward this group. Considering that they are professionals who work actively in different social contexts, their training on gender and transgender issues is important ( Gavilán, 2015 , p. 85).

The second objective was to analyze the attitude of Social Education students toward transgender people. According to the hypothesis of the study, it was expected to find positive attitudes toward transgender people because of the sensitivity or respect that is expected of students in the degree of social education toward disadvantaged groups. In this case, a fairly low transphobia and gender aggressiveness score was found, which is why this hypothesis was affirmed. Also in a study with a sample of 668 people, positive attitudes toward transgender people were found, such as the recognition of the right to adoption, among others ( Landén and Innala, 2000 ). Fortunately, there are populations such as health professionals and feminist communities that have positive attitudes toward transgender people ( Franzini and Casinelli, 1986 ; Kendel et al., 1997 ). From this study it can be deduced that the Social Education student body is also a population with positive attitudes toward this group. Regarding negative attitudes, several studies have found that transgender people experience violence and discrimination ( Lombardi et al., 2001 ; Hill and Willoughby, 2005 ), which prevents them from being able to behave according to their identity because of the inadequate treatment they received ( Hill and Willoughby, 2005 ; European Union Agency for Fundamental Rigths [FRA], 2013 ). This research shows that 85 and 71%, respectively, of the mockery that has been directed at women for showing a male aspect or behavior or at men for their female aspect or behavior, state that they have not made any mockery and 92% have not behaved violently toward women for their male behavior or toward men for their female behavior. Aversion or fear of transgender people (e.g., male women and female men) are attitudes that are part of transphobia ( Hill and Willoughby, 2005 ) and need to be eliminated.

In terms of gender differences, the results of this study show that men have lower scores than women on gender bashing and transphobia/genderism. Despite a small sample of men compared to women, men showed significantly more discriminatory responses than women on the gender bashing scale. The results also suggest there may be more transphobia in men than in women although the results are not statistically significant. These findings coincide with other studies showing that men have more transphobia than women ( Landén and Innala, 2000 ; Nagoshi et al., 2008 ; Norton and Herek, 2013 ; Elischberger et al., 2016 ; Kanamori and Cornelius-White, 2016 ).

In reference to the third objective, the aim was to study the changes given in attitude and knowledge in the students of Social Education after receiving training on the transgender subject. It was expected to find an improvement after the training through the creative factory methodology. This hypothesis has been partially fulfilled, given that no differences have been collected in the improvement of attitudes toward the collective; one explanation may be that from the beginning the average of transphobia and gender aggressiveness found was low and although in transphobia an improvement is observed, this has not turned out to be statistically significant. Range restriction (the mean was already very high on the scale, indicating low transphobia) may account for the finding, suggesting that future studies should use measures with a wider range that may be more sensitive to change.

On the other hand, there has been a statistically significant difference in the perceived knowledge on the subject of transgender, having increased the knowledge after receiving the training, so it can be stated that the training received has made it possible for the participating students to increase their knowledge. In a previous investigation with students and teachers in the field of health, it was found that after a training of 8 h the knowledge, attitudes and clinical preparation toward people of sexual and gender minorities improved with respect to the control group that had not received any training ( Pratt-Chapman and Phillips, 2019 ). Thus, learning programs on transgender issues improve both knowledge and attitudes toward transgender people. For this reason, the importance of promoting training courses on gender and transgender for professionals so that they can act and intervene both in educational spaces and in family, work and community spaces ( Parcerisa-Aran and Forés, 2003 ; Bas-Peña et al., 2014 ) is highlighted.

This training program on gender and transgender has created a context of reflection and knowledge generation for students using the creative factory methodology (OTS, 2016). This methodology makes use of creativity and, thanks to this, facilitates the capacity to adapt to new changing contexts and can contribute significantly to society ( Goñi, 2000 ; Chacón and Moncada, 2006 ). In this study, it has been demonstrated that through the creative factory methodology, changes can be achieved both in attitudes and in the students’ knowledge about gender and transgender issues. This demonstrates that the methodology has served to improve knowledge on transgender issues.

The current study is subject to several limitations. The use of a single item measure to measure the students’ perception of transgender knowledge is one obvious drawback as reliability and validity information are not available for the use of this measure. The lack of a control group and the small sample size for a quantitative study offer further constraints for the internal and external validity of the study. Future research could employ more validated measures, comparison groups using no intervention or other interventions to compare effectiveness and larger, more diverse Spanish speaking sample sizes. Future lines of research also aim to collect information from university students of different grades. In this way, it will be possible to carry out a comparative analysis between students from different disciplines. Another future line of research is to carry out a qualitative study where the results are focused on the innovative contributions of the students. In this case, an analysis of the good practices and innovative ideas presented by the students will be carried out.

As mentioned above, despite the importance of gender training for Social Education students, studies show that they receive little training on the subject ( Bas-Peña et al., 2014 ). An objective for future studies is to continue creating this type of training both at the Social Education level and at other levels for which it is even more necessary to develop skills in relation to the relationship and treatment with people, in order to continue promoting awareness and learning about gender and transgender issues.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethics Committee for Research Related to Human Beings (CEISH) of the University of the Basque Country. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

MG, NO-E, and EJ-E were involved in the conceptualization of the project and involved in the acquisition of data and analysis. MG, NO-E, EJ-E, and JC-W were involved in the interpretation of the data. All authors were involved in the drafting and revising of the work for intellectual content, provided approval for submission for publication of the content, and agreed to be accountable for the accuracy and integrity of the project.

Conflict of Interest

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

Acknowledgments

The researchers wish to thank the participants for their willingness to engage with the creative factory and contribute to the study.

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Keywords : transgender people, attitudes, sexual education, social education, social change

Citation: Gorrotxategi MP, Ozamiz-Etxebarria N, Jiménez-Etxebarria E and Cornelius-White JHD (2020) Improvement in Gender and Transgender Knowledge in University Students Through the Creative Factory Methodology. Front. Psychol. 11:367. doi: 10.3389/fpsyg.2020.00367

Received: 10 January 2020; Accepted: 17 February 2020; Published: 13 March 2020.

Reviewed by:

Copyright © 2020 Gorrotxategi, Ozamiz-Etxebarria, Jiménez-Etxebarria and Cornelius-White. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Naiara Ozamiz-Etxebarria, [email protected]

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October 23, 2020

The Disturbing History of Research into Transgender Identity

Research into the determinants of gender identity may do more harm than good

By Jack Turban

Nolwen Cifuentes Getty Images

In 1975 psychiatrist Robert Stoller of the University of California, Los Angeles, wrote something bizarre in his textbook on sex and gender. He asserted that people who were assumed to be boys when they were born but whose gender identity or expression did not match that assumption “often have pretty faces, with fine hair, lovely complexions, graceful movements, and—especially—big, piercing, liquid eyes.” Based on this observation, he suggested a theoretical model in which transgender girls become transgender because they are especially cute. Society treats them more like girls, he reasoned, and because of this experience, they start to identify as female.

As a physician-scientist, I’m generally of the opinion that knowledge leads to progress. But studies focused on this particular question—those asking what determines someone’s gender identity—have led us down some strange and dangerous paths. Researchers in this area appear to be in search of some objective truth, but the science is rooted in a subjective assumption: that we need to know what makes someone transgender so that they can be “fixed.” As a result, scientists have relentlessly pursued such questions, launching studies that promoted ideas that could hurt transgender children and their families.

Stoller’s observations motivated many of the psychological theories behind what makes people transgender. In 1993 a group of researchers at the Clarke Institute of Psychiatry in Toronto set out to test his hypothesis that beauty and what was then called “gender identity disorder” were linked. They recruited 17 birth-assigned boys with the diagnosis and 17 birth-assigned boys without it , all around the age of eight. The researchers then took headshots of the children and showed them to 36 college students. The students were asked to rate the youngsters’ physical appearance on a scale from one to five with categories such as “attractive,” “handsome” and “beautiful.” In the end, the college students found the children with “gender identity disorder” to be “prettier” than the cisgender boys. The findings seem to suggest Stoller was right: perhaps, because of their appearance, people treated the youngsters in the former group more like girls, and consequently, they became transgender. Though as the authors mention later in the paper, an equally plausible theory is that these children could have altered their appearance (long hair, et cetera) in ways that matched their identity, leading the college students to associate them with more feminine descriptions such as “pretty.”

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A few years later, researchers revived this line of investigation , using the headshots of young birth-assigned girls with “gender identity disorder.” A group of college students again rated how “ugly” or “pretty” these children appeared, compared with cisgender girls. The children with “gender identity disorder” were rated as less beautiful, prompting the researchers to suggest that they may have been treated more like boys and thus identified as male. It seems more likely that these children simply cut their hair shorter, so the participants attached more masculine words to them. In the end, the study didn’t reveal much about what makes someone transgender, but it did promote an offensive theory with the potential to diminish the self-esteem of vulnerable transgender youth.

Researchers also studied the parents of such children. Psychiatry has long been enamored with the theory of mothers harming the development of their children (for example, the refrigerator mother theory posited that autism was caused by a lack of maternal warmth). These studies similarly asked if perhaps parents were to “blame” for their kids’ gender identity. In one paper, researchers assessed whether the mothers of children with “gender identity disorder” had more symptoms of either depression or a condition called borderline personality disorder. They found these mothers had more symptoms of both. Sounds convincing, right? Children must become transgender because their mothers are mentally ill.

What the researchers failed to discuss was that the mothers’ symptoms could easily have been caused by the way society treated their children. The subscale of borderline personality disorder that was higher among them was “interpersonal conflict.” You don’t need to be the parent of a transgender child to imagine that raising your kid in an unaccepting community could create substantial conflict.

In another study, researchers noted that parents of children with “gender identity disorder” did not place strong limits on stereotypically gender atypical behaviors such as birth-assigned boys playing with dolls or birth-assigned girls playing with blocks or transportation toys. Perhaps this was the cause of the “problem”? If these parents had simply cracked down on this behavior early on—ripped the Barbie out of their toddler’s hands, say—they may have prevented it, the authors posited. The more likely explanation is that it’s difficult to take a doll away from a child who desperately wants to play with it. And that doing so makes them sad and impacts their self-esteem.

In each case, researchers were hyperfocused on finding a problem with either the kids or their parents. But in the end, these scientists failed to establish one. They seemed less interested in a vital reframing: perhaps the issue was not the children’s identity but the way society treated them. Instead of supporting these kids, the researchers labeled them unattractive or painted their parents as mentally unstable.

These theories on the origins of gender identity have only added to the misguided, and increasingly illegal, calls for “therapies” designed to make transgender people cisgender. The logic of so-called gender identity conversion therapy is that if the environment is the cause, then we can simply alter the environment to nip things in the bud. Most of the “conversion” manuals have not been released to the public, but in 2002 a psychologist at Columbia University published “ Gender Identity Disorder in Young Boys: A Parent and Peer-Based Protocol ,” which included parenting techniques such as “letting go of [the] boy by [the] mother,” forcing the child to play with same-sex friends, and removing the youngster from stereotypically gender-atypical activities such as gymnastics or ballet. Notably, a recent study my colleagues and I conducted showed that attempts to change a child’s gender identity from transgender to cisgender are associated with greater odds of attempting suicide. Several U.S. states have banned conversion therapy, but in much of the U.S., these practices continue.

Similar research into the psychological causes of transgender identity continues even today. A physician at Brown University recently conducted an anonymous survey of respondents recruited via Web sites for parents who believe peer pressure and online influences have made their children transgender. The survey essentially asked the parents if they thought the Internet made their children trans , and the parents, not surprisingly, given that they were visiting Web sites about this idea, answered yes. Conservative media latched onto the study, suggesting that transgender children are really just confused kids tricked into being transgender after reading something on Reddit. The implication is that we need to take these kids away from supportive online LGBTQ communities so that they can be made cisgender again. Reading through this literature, we need to ask ourselves some questions: What is the reason for this research? What does it hope to accomplish? The tireless search reveals a thinly veiled dogma: that being transgender is a pathology to be fixed. This belief not only harms transgender people but also undermines good science.

What good science shows us is that when we accept transgender people, they thrive . Instead of trying to figure out what went “wrong,” we should be investing our time and energy into advocating for nondiscrimination laws, increasing access to health care and raising transgender voices in the media, so society realizes that they are vital members of our communities. Maybe Stoller was right when he noted that those children were exceptional. It’s time we celebrate that and move on.

Jack Turban is a fellow in child and adolescent psychiatry at the Stanford University School of Medicine, where he researches the mental health of transgender youth. His writing has appeared in the New York Times, the Washington Post, the Los Angeles Times, and more. Follow him on Twitter @jack_turban .

Research article
Open access
Published: 18 February 2021

A qualitative study examining transgender people’s attitudes towards having a child to whom they are genetically related and pursuing fertility treatments in Greece

P. Voultsos 1 ,
C.-E. Zymvragou 1 ,
M.-V. Karakasi 2 &
P. Pavlidis 2

BMC Public Health volume 21 , Article number: 378 ( 2021 ) Cite this article

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Advances in biomedical technologies permit transgender individuals not only to achieve gender transition but also to experience parenthood. Little is known about this topic in Greece, which, although a traditionally conservative country, is changing at the legal level towards a greater recognition of transgender people’s rights. This study aimed to investigate transgender people’s attitudes towards having a child to whom they are genetically related and pursuing fertility treatments in Greece.

This is a prospective qualitative study conducted with adult individuals who identified as transgender men or transgender women between April 2019 and March 2020. Individual in-depth qualitative interviews were conducted with 12 participants. The interviews were carried out in person and were digitally recorded and transcribed verbatim. We performed a thematic analysis of the data.

The thematic data analysis resulted in the identification of themes that represent key barriers to pursuing fertility preservation or the use of assisted reproductive technology. Six major themes were clearly present in the findings (lack of adequate information and counseling, worsening gender dysphoria, increased discrimination against transgender people due to the rise of extreme far-right populism, low parental self-efficacy, high costs, and a less-than-perfect legal framework). Moreover, diverse cases were examined, and minor themes, such as the symbolic value of the uterus and pregnancy, the relationship between the type of gender transition and willingness to pursue fertility treatments, and transgender people’s adherence to heteronormative patterns in the context of reproduction, were identified. Various reasons for transgender people’s differing degrees of desire for parenthood were identified.

Our findings demonstrated contextual factors as well as factors related to transgender people themselves as barriers to pursuing transgender parenthood. Most aspects of our findings are consistent with those of previous research. However, some aspects of our findings (regarding aggressive behaviors and economic instability) are specific to the context of Greece, which is characterized by the rise of extreme far-right populism due to the decade-long Greek economic crisis and a deeply conservative traditionalist background. In that regard, the participants highlighted the (perceived as) less-than-perfect Greek legislation on transgender people’s rights as a barrier to transgender (biological) parenthood.

Peer Review reports

An increasing number of young transgender people today are using medical procedures such as gender-affirming hormonal or surgical therapies to achieve gender transition Footnote 1 [ 1 , 2 ]. Gender transitioning is ‘the process of changing one’s gender presentation and/or sex characteristics to accord with their internal sense of gender identity’ [ 3 ]. Importantly, in the past, young transgender people never sought gender-affirming care (i.e., hormonal) as part of the transition process at earlier stages of development [ 1 ]. While research has shown that gender-transitioning people experience psychological benefits [ 4 ], the multifaceted process of gender transitioning with hormones or sex reassignment surgery may introduce a higher risk of significant long-term implications, including temporary or permanent loss of fertility [ 5 , 6 ]. Notwithstanding, recent advances in biomedical technologies have not only enabled gender transition but also made it feasible for transgender individuals to experience parenthood. Most transgender people who become parents do so through biological means [ 7 ]. At present, fertility preservation (FP) techniques include sperm banking for transgender women and oocyte, embryo, or ovarian tissue banking for transgender men, while new FP techniques may be developed in the future. For instance, uterus transplantation may become available in the future (although not the foreseeable future) for transgender women.

Consequently, transgender people face complex and difficult decisions about whether to freeze sperm or eggs or use assisted reproductive technology (ART) [ 6 ]. The introduction of alternative means of achieving biological parenthood through medical advances has, therefore, created new forms of families including (at least) one transgender person. However, ‘the uptake of this option to date has been low’ [ 8 ]. A few years ago, the academic literature suggested that little was known ‘about how transgender people create their families and the issues involved in these decisions’ [ 9 ]. More specifically, it was stated that ‘little is known about their desire to have children and attitudes towards fertility preservation options’ [ 10 ]. Moreover, it was argued that because there was little knowledge about the complex topic of ‘medically assisted reproduction among transgender people’, more clarification was needed [ 11 ]. However, there is now a substantive body of research on the creation of families by trans people, and there has been a significant increase in research on FP over the past few years [ 7 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Recently, Sterling and Garcia conducted a systematic literature search of PubMed, Medline and Google Scholar and identified several publications related to the topic of interest [ 20 ].

This manuscript attempts to expand knowledge about transgender adults’ attitudes and desires related to family formation and FP in Greece, as further empirical research is needed to provide a more nuanced exploration of transgender people’s rights, including their right to equal access to healthcare services [ 21 ]. There is a lack of empirical evidence to support an understanding of what it is like for transgender people in Greece to make a decision about whether to pursue FP or ART. Greek society is traditionally conservative. However, within the recently changing legal framework that greatly strengthened transgender rights by allowing citizens to choose to legally change their gender identity, more transgender people are expected to use fertility clinics. If this is the case, fertility clinics will face an entirely new patient group (transgender people) ‘whose reproductive futures were previously considered either impossible or undesirable [and] are now “anticipating infertility” and engaging in “family planning” as central parts of their lifecourse and medical engagements’, as Payne and Erbenius (2018) wrote with respect to Sweden [ 22 ].

The legal status of transgender people in Greece

Since 2013, the Greek Criminal Code has punished gender identity discrimination and violence, and this legal protection was enhanced by the anti-racism law, Law n.4285/2014. Nevertheless, over recent years, Greece has adopted extreme austerity measures that have led to the rise of far-right parties. Consequently, homophobic and transphobic physical and rhetorical violence have substantially increased [ 23 , 24 ]. More recently, Law n. 4491/2017 allowed citizens to choose to legally change their gender identity (from the age of 15). Importantly, this law improved transgender people’s right to change their official gender registration according to their own understanding of their gender identity without requiring gender-affirming treatment. Under the new law, young people (between the ages of 15 and 17) can apply for legal changes in their gender identity after having obtained a certificate issued by a medical council (in Athens Children Hospital). The law brings Greek legislation in line with the legislation of most EU countries [ 25 ], and Transgender Europe (2017) welcomed this law [ 26 ]. Undoubtedly, this law is an important step in improving transgender people’s autonomy. Note, however, that transgender people who already have children when they apply for a legal change to their gender identity are presented on the registry certificates of their children according to their former gender identity (their sex assigned at birth). As a consequence, the current legal framework ‘prevents’ transgender parents from applying for legal changes to their gender identity.

Unsurprisingly, legal amendments can hardly alter issues that are rooted in culture [ 24 ]. The Orthodox Church of Greece has profoundly shaped Greek people’s moral and social attitudes for many years. The Orthodox Church of Greece stated that the Law n. 4491/2017 was ‘a satanic deed’ that will lead to ‘the destruction of social cohesion…’ [ 25 ]. Greek cultural values place considerable emphasis on heterosexual coupledom, promoting the view that it is a prerequisite for personal fulfillment [ 27 ]. Religion is a major factor that strongly influences Greek culture, particularly regarding sexuality and marriage.

In Greece, Laws n.3089/2002 and n.3305/2005 constitute a regulatory environment that is largely liberal compared to those of many other European countries and that allows citizens to access in vitro fertilization (IVF) techniques such as heterologous fecundation (assisted fertilization of a woman’s oocyte with donor sperm), surrogacy, postmortem fertilization, cryopreservation and donation of gametes or zygotes. Under the current Greek legal framework, IVF is permitted only for strictly medical reasons, namely, for individuals ‘unable to have children naturally’ (Greek Civil Code, article 1455§1). Hence, access to IVF techniques is not granted to same-sex couples or single men. However, a lesbian trans woman can access IVF techniques by presenting herself as a ‘single woman’ wanting a child (Law n. 3089/2002 in combination with Law 4491/2017). ‘Trans women can opt for semen cryopreservation prior to their gender-affirming transition to retain the possibility to parent genetically related offspring’ [ 28 ]. Trans women may seek surrogacy to achieve genetic parenthood.

Methodological aspects

The present work is a prospective qualitative research study centered on exploring the social realities of individuals who identify as transgender and their descriptions of their lived experiences and attitudes towards having biological offspring. Data were collected through semistructured in-depth interviews conducted in person with 12 individuals who identified as transgender men or transgender women between April 2019 and March 2020.

Research questions

The primary research question that defined the focus of this study was as follows:

What are the attitudes of adult transgender women and transgender men towards having a child to whom they are genetically related and pursuing fertility treatments in Greece?

The secondary research questions were as follows:

What are the factors (if any) affecting transgender individuals’ fertility decisions?

What are the challenges (if any) that transgender people face in accessing fertility treatment or pregnancy and birth services?

We followed each of the items listed in the COREQ (COnsolidated criteria for REporting Qualitative research) checklist [ 29 ].

Research team and reflexivity

Personal characteristics.

C-E Z conducted the interviews. She is a psychologist who was pursuing a master’s in bioethics at the time of the study and has experience in conducting qualitative research interviews. PV is an Associate Professor of Medical Ethics, V-M K is a physician (psychiatry resident), and PP is an Associate Professor of Forensic Medicine.

Relationship with participants

No relationships between the interviewer and participants were established prior to study commencement. The interviewer’s reasons for doing the research as well as her interest in the research topic were reported to the participants.

Study design

Theoretical framework.

Thematic analysis (a widely used qualitative research technique) was selected as the methodological orientation to underpin the study.

Participant selection

Purposive sampling was used to deliberately identify individuals who identified as transgender persons and potentially had experience with transgender parenthood and fertility treatment. Purposive sampling was used to select individuals willing to provide detailed information about their perceptions, attitudes and experiences of having biological offspring and pursuing FP and/or in vitro fertilization techniques. The participants represented a wide range of ages and diverse socioeconomic backgrounds. Initially, we approached people who identified as transgender (but not nonbinary) persons using the interviewer’s (C-E Z) personal contacts. Overall, 12 participants were recruited through community outreach and the interviewer’s personal contacts. Potential participants were approached in person, by phone or by email and then contacted by phone to schedule an interview. None of the potential participants refused to participate or dropped out. Recruitment continued from April 2019 through March 2020, reaching a total of 12 participants. After first contact, all of the individuals were told that the purpose of the study was to understand the attitudes of trans people towards undergoing FP and having biological offspring in Greece and that the interview was expected to take between 30 and 60 min to complete. After agreeing to participate, the participants received a brief explanation of the objectives and the policies regarding anonymity, voluntary participation and confidentiality of the study. All interviews were conducted in Greek.

The interviews were conducted in neutral places of the participant’s choice. All interviews were held in quiet places (most often private rooms) with a comfortable environment. As phenomenological researchers, we were interested in describing the participants’ experiences while maintaining a natural (normal, unreflective and effortless) attitude. No one aside from the participant and interviewer was present at the interviews.

Description of the sample

The selected study participants ( N = 12) were individuals who identified as transgender men and women and were in different stages of transition; they were diverse in terms of age, gender identity, transition phase or type, place of residence, sexual orientation, and educational background. The age of the participants ranged from 23 to 60 years, with the majority being between 27 and 45. The mean (standard deviation, SD) age of the participants was 40 (11) years. All participants were adults and had been Greek citizens for at least the last 10 years. All participants resided in urban areas. The participant characteristics are presented analytically in Table 1 .

Data collection

The interviews were conducted one on one. The interview guide was developed based on a review of the relevant literature and then, as a first step, pilot tested. The guide was slightly refined based on the initial results from a few interviews to help the participants to better understand the specific issues being asked about in the questions. We next developed an informal grouping of topics and questions that the interviewer could ask in different ways for different participants. The interview guide covered a number of topics to capture a wide range of the participants’ lived experiences. These topics were related to a) making fertility decisions and b) accessing fertility treatment and health care services. The participants were encouraged to expand upon the examined topics. They were asked broad questions and encouraged to respond in a conversational way to express themselves. The interviews were semistructured and started with questions such as “What was it like to be a transgender parent, and what does it mean to you?” ( a grand tour question to make the participant comfortable ), “How do you think other transgender people perceive having a child to whom they are genetically related?”, “What would motivate or did motivate you to pursue or not pursue parenthood?”, “What do you know about other transgender people’s experiences or attitudes towards pursuing fertility preservation or in vitro fertilization techniques?”, and “Can you please describe in detail what types of barriers a transgender person needs to overcome to pursue fertility preservation or in vitro fertilization techniques?”. The set of interview guide questions is presented in [Additional file 1 ] (Supplementary Material). Additional questions were asked to elicit more detailed explanations and identify the essential themes of transgender people’s attitudes towards having a child to whom they are genetically related and pursuing fertility treatments.

We did not carry out follow-up interviews. The interviewer audio-recorded the interviews to collect the data. In addition, field notes were made after the interview to record nonverbal behavior patterns, as well as procedural and contextual aspects of the interviews, which enabled deeper and contextual critical reflection on the data collected. The interviews lasted from 38 min to 55 min each (mean 44 min). They were digitally audio-recorded and transcribed verbatim to preserve authenticity. We stopped data collection when we believed data saturation had been reached, namely, when no additional information was obtained from further interviews. The interview transcripts were not returned to the participants for their comments and/or corrections.

Data analysis

The research data were gathered by combining conversational interviewing and structured interviewing to yield insightful findings. The interviewer spent the first part of the interview gaining the participants’ trust. For this reason, in all the interviews, the initial rapport-building was devoted to addressing the apprehension phase of the interview process [ 30 ]. This phase was largely devoted to discussing topics not directly related to the research topic, such as gender dysphoria, social stigma and discrimination, and the gender transitioning process. Interestingly, this part of the interviews was found to be useful for improving the data interpretation in the thematic analysis.

Qualitative data were analyzed using thematic analysis [ 31 ]. As we wanted to work with our research participants as collaborators, examining their different perspectives, we used the flexible method of thematic analysis, which can generate unanticipated insights [ 31 ]. As transgender men’s experiences of barriers in making fertility decisions or accessing fertility treatment or pregnancy and birth services had not been previously explored in the context of Greece, we were not already aware of the participants’ probable responses. We followed Gibbs’ (2007) [ 32 ] advice on demonstrating qualitative reliability. Furthermore, thematic analysis was conducted to produce trustworthy and insightful findings and “to make sense of the data, and tell the reader what it does or might mean” [ 33 ].

Verbatim transcription of the audio-recorded narratives was performed. In the first step, we read through the entire data set at least once to familiarize ourselves with all aspects of the interview data, capture initial thoughts and take notes before beginning coding. In a second step, we identified important sections of text and attached initial codes to indicate them as related to themes in the data. While generating the initial codes, we highlighted similarities and differences in the perspectives of different research participants. Then, in a third step, we maintained detailed notes about the hierarchies of themes to be included in the devised set of themes. In a fourth step, we reviewed the themes and, more specifically, the coherence between the coded data extracts. We checked whether there was some overlap between themes and whether some themes might need to be broken down into separate themes [ 33 ]. In the fifth step, we defined and named themes, writing a detailed analysis of each one individually. It should be highlighted that we allowed sufficient time for all of the data to be read through and the coding to be reviewed at least twice. Moreover, we coordinated communication and shared analyses. We strived to capture and investigate in depth all aspects of the participants’ narratives related to the research goal.

A data management software program (NVIVO, 2015) was used to manage the data, namely, to secure and further refine the systematic character of the analysis. The participants did not provide feedback on the findings. Participant quotations are presented to illustrate the themes and findings. Each quotation is identified with the pseudonym of the participant. There is consistency between the data presented and the findings. Five major themes were clearly identified in the findings (lack of adequate information and counseling, worsening gender dysphoria, increased discrimination against transgender people due to the rise of extreme far-right populism, low parental self-efficacy, and high costs). Moreover, diverse cases are described, and minor themes (such as the symbolic value of the uterus and pregnancy, the relationship between the type of gender transition and the willingness to pursue FP and IVF, and transgender people’s adherence to heteronormative patterns in the context of reproduction) are discussed.

Reflexive thinking was used throughout the research process to reduce unintentional personal bias. We strived to use reflection to increase awareness of our preunderstanding of the study phenomenon in order to minimize any bias of our own influence. Each of us engaged with the other researchers to limit research bias.

Ethical considerations

The interviews were conducted in neutral places of the participant’s choice, thereby ensuring privacy and confidentiality and minimizing environmental impact. We adhered to the ethical principles of anonymity, voluntary participation and confidentiality. The participants’ anonymity and confidentiality were maintained throughout the study: to preserve their anonymity, pseudonyms were used to describe participants in this study, and the interviews were registered and stored in a strictly confidential fashion.

The analysis of the study findings resulted in the identification of the following themes that represent key barriers to pursuing FP or ART: lack of adequate information and fertility counseling, worsening gender dysphoria (fertility treatment may be a challenge to the transition process or a result of it, with the strength of the desire for fertility treatment being crucial), increased discrimination against transgender people due to the rise of extreme far-right populism, low parental self-efficacy, high costs, and the less-than-perfect legal framework. Not all participants expressed a strong desire to have offspring. Various reasons behind transgender people’s desire for parenthood were identified. A number of subthemes were grouped under the base themes, such as the symbolic value of the uterus and pregnancy, the relationship between the type of gender transition and willingness to pursue FP and IVF, and transgender people’s (especially those in social transition) striking adherence to heteronormative patterns in the context of reproduction.

Lack of fertility counseling

None of the participants reported having received adequate FP counseling before starting their transition, and 6 out of 12 participants indicated that they had not been given adequate information about their FP options.

The participants Jessie (a trans woman who was between 45 and 55 years old and had completed the transition process Footnote 2 ), Luis (a trans man who was between 25 and 35 years old, still in transition), and Jonathan (a trans man who was between 25 and 35 years old, still in transition) did not express regret about the missed opportunity for receiving further information from their psychologist/psychiatrist or endocrinologist about FP. However, the participants Fabiola (a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process), Edward (a trans man who was between 30 and 40 years old, at an advanced stage of the transition process), and Patrick (a trans man who was between 25 and 35 years old and had completed the transition process) made clear complaints about being deprived of the opportunity to make fertility decisions, namely, to have a choice about having children genetically related to them. Furthermore, the participants noted that when they were adolescents in the gender transition, they did not feel ready to make important and lifelong reproductive decisions. However, they were forced to consider whether to preserve their sperm or eggs.

Fabiola, a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process, stated,

“…A health scientist should have informed me about it... and I went as early as 16... this is what I tell other youngsters, that, ‘OK, you may not be interested in becoming a parent now, but you never know what might happen ten years from now’... no information is given to us...”

In the same vein, Edward and Jonathan stated that they were not provided with fertility counseling before starting gender transition [for more details, see Additional file 2 (Supplementary Material)].

Fears of discrimination, bullying, and harassment as barriers to transgender parenthood

Bullying by the general population: Discrimination, bullying, and harassment during pregnancy

The participants expressed fears of discrimination ranging from subtle forms (such as social disapproval) to physical violence. They expressed their fear of aggressive behaviors against them, highlighting the rising extreme far-right populism in the urban areas where they were living.

The fact that the phrase ‘transgender parent’ gives other people a negative impression was reported as discouraging to transgender people with regard to considering FP and assisted reproduction options. Patrick, a trans man who was between 25 and 35 years old and had completed the transition process, said,

“... it sounds bad... when you say ‘trans parent’, they immediately think, as soon as they hear it, that it is very strange...”

Fabiola, a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process, highlighting the fear that extreme far-right populist persons may become violent, stated,

“Imagine a trans man pregnant walking in the town square... to start with, it is dangerous for the person themselves, for their physical integrity…”.

Fay, a trans woman who was between 45 and 55 years old, still in transition, believed that a transgender parent may be at high risk of bullying by other people as long as she remains visible as a transgender person. However, the participant expressed fears of another form of bullying that may be experienced by transgender parents even if they keep their transgender identity invisible. This form of bullying (the forced removal or separation of children from their parents) occurs in a transgender parent’s family context or is instigated by close relatives [see her quotes below, Additional file 2 (Supplementary Material)].

Bullying by health providers in birth settings

A trans man who goes to the hospital or a midwifery unit to give birth may commonly be the subject of bullying by health professionals. George, a trans man who was between 55 and 60 years old who had completed the transition process and was bisexual, expressed his fears:

“The only problem is society, when you go to a maternity clinic with a beard... You will have to be able to go for prenatal birthing classes; you need to receive treatment in an atmosphere of understanding at the hospital, not to be abused.”

Fabiola, a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process, said,

“... and how would they be treated during delivery? Does such a person, in other words, have to be rich and go to a private clinic and pay so they are treated with dignity? This does not mean that there are not people in the public health system who do not treat you with dignity [she relates her experience].”

Unfortunately, health professionals were reported to be the originators of bullying behavior not only within reproductive healthcare contexts but also within other healthcare contexts. Two participants (Fabiola and Edward) described negative experiences with health providers that reflected their providers’ lack of willingness to offer appropriate healthcare to transgender patients. More specifically, they described instances in which health professionals demonstrated subtle (verbal and ‘low-intensity’) bullying-related behavior or at least a lack of empathy for the issues faced [see their quotes below, Additional file 2 (Supplementary Material)].

The transition process as a barrier to FP and assisted reproduction

FP as a challenge for the break with one’s old gender

Jessie, a trans woman who was between 45 and 55 years old and had completed the transition process, was highly concerned that sperm storage would strongly challenge the (highly desired) break with her old gender identity. She explicitly declared that it would be distressing (for reasons related to gender dysphoria) to pursue FP and explained,

“... there was no such suggestion by anyone; even if there had been such a discussion, I would not have even stood to hear about it; I wanted to erase any trait left... It is out of the question that I would give my sperm for a biological child... I think this is because it would reduce my female substance (!)… I don’t even remember myself... It’s as if a roller shutter has come down, a curtain, and I cannot see the past... I try to remember me, and I cannot remember me...”

[In the same vein, the representative quotes of four other participants are presented below, Additional file 2 (Supplementary Material)].

Interestingly, Jessie said that if she had been given the opportunity to undergo uterus transplantation at a younger age, it would have significantly contributed to the success of her transition. As the topic of uterus transplantation was not covered in the interview guide questions, this mention of uterus transplantation came up as an emergent theme. The participant stated,

“… in other words, it would be continuing on the way to a sense of completion... 100%; I would have felt completed, but, OK, this did not take place when it should have...”

The highly symbolic value of pregnancy (considered strictly related to femininity) as a barrier to FP and assisted reproduction for individuals undergoing female-to-male gender-affirming transition

We found that trans men may be very unwilling to become pregnant, whereas they may be willing to become genetic parents.

Antonio, a trans man who was between 35 and 45 years old, still in transition, reported his unwillingness to become pregnant, but he had a strong desire to have children and a family. He was willing to pursue FP and donate oocytes. He stated,

“ …I am all for having a family and children. Hmmm... if my girl wants to get pregnant, if that is her intention [she is in a wheelchair]; I don’t want to. I want to proceed with the removal, so this will never happen. Any kind of surgery to freeze my ova so that they may be fertilized, if this is possible...”

Nevertheless, John, a trans man who was between 40 and 50 years old, in social transition, was much more willing to donate gametes (oocytes) than many other participants. Strikingly, he noted that he could not understand why many trans men are not willing to become pregnant, as the desire for parenthood may be stronger than the desire for gender transition. He stated,

“Yes, absolutely, yes, yes, yes, [I would like to donate an ovum]... this is why, if I am going to receive hormones, I will discuss it a lot with my doctor... after their transition, trans persons do not want to have children as... hmmm... using their body. If you ask me about it, I would say that they would like their boyfriend or girlfriend to do it with another person or to adopt... the question is what [do] you want more: to be a trans person or to be a father? To be a trans person or to be a mother?...”

Notably, however, some trans men believed that a trans man might become pregnant and give birth after the gender transition. George, a trans man who was between 55 and 60 years old who had completed the transition process and was bisexual, said,

‘They say that I should have completed the transition and then had children… [If you get pregnant]… the only problem is society, when you go to a maternity clinic…not to be abused’.

Placing considerable value on genetic relatedness encourages the willingness of transgender people to become biological parents

The participants reported several reasons for their willingness (or unwillingness) to become biological parents. We remarked on the differences between responses and attitudes related to fertility desire and those related to having children during the interviews. The participants were not always clear about the reasons behind a transgender individual’s willingness or unwillingness to have a child to whom they are genetically related, and the interviewer often needed to ask directly.

The participants in the present study indicated that the desire to have a child to whom they are genetically related has a deeper meaning than just a wish. While rationalizing transgender people’s desire to have a child to whom they are genetically related, the participants discussed several reasons for this desire. For example, Patrick, a trans man who was between 25 and 35 years old and had completed the transition process, placed considerable emphasis on the value of genetic relatedness and biological resemblance between parents and children as the reason behind the desire for biological parenthood and stated,

“Simply because of the reasons anyone has: that they want to feel it is their own child, made with their own material... to see some features in this child... biological ones.” [more quotes of Patrick are presented below, Additional file 2 (Supplementary Material)].

In a similar vein, Fay, a trans woman who was between 45 and 55 years old, still in transition, believed that a transgender person’s desire to have children is based on an innate human need to have children and noted,

“Someone who is a trans individual does not stop wishing they had a child... Just like with cis… I believe that [the wish to have a child] emerges purely from the biological need each individual has.”

However, this participant thought that the strong desire for parenthood motivates a transgender person to pursue FP techniques and ART and stated,

“Now, I don’t know if a trans woman would undergo the procedure to have a biological child… only if she truly wants it…” “…I believe things are completely different for homosexuals…”.

Fabiola, a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process, highlighted that the desire for biological parenthood is egoistically motivated and stated,

“[I would like a child] for the same selfish reasons any cis person does; I don’t believe [there is] some biological clock... eh, the feeling has to do with selfishness...”

This view deviated from the dominant culture that highlights essentialism (biology and naturalness). However, on the other hand, the abovementioned participant took a clear stance in favor of biological ties between parents and children. Fabiola missed the opportunity to have her own children (due to a lack of information about FP options before starting her transition) and stated,

“... what I expect for the future is for my partner to have a child... it would be our child... because this would be my first thought before adoption...”

Below, Additional file 2 (Supplementary Material) presents more representative quotes of other participants. Jenny strikingly underscored the role of the so-called ‘biological clock’ in shaping the desire for biological parenthood. She was strongly in favor of the natural way of conceiving a baby and strongly rejected the use of medically assisted reproductive techniques. Namely, she remained strikingly steadfast in her adherence to patterns of the dominant culture (based on naturalness/biology and heteronormativity), at least in the context of reproduction. Patrick highlighted the genetic relatedness between parents (more quotes are presented). In contrast, Richard did not emphasize the biological ties between parents and children.

In conclusion, the analysis revealed that transgender people are most likely to have the same basic reproductive needs as cis people, and some transgender individuals place great weight on the value of genetic relatedness.

Concerns related to transgender parenting and children’s welfare as barriers

Transgender people’s fears that their children will be affected by bullying

Fabiola, a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process, highlighted the social prejudice and discrimination faced by children with transgender parents and stated,

“…In the local community [reference to the name of the person’s village of origin], even an adopted child is at times pointed to and called a bastard.”

Interestingly, in the data analysis, fear of social prejudice did not emerge as the main barrier to transgender parenthood related to a child’s welfare.

Surprisingly, Jessie, a trans woman who was between 45 and 55 years old and had completed the transition process, took a clear stance against same-sex parenthood while being in favor of transgender parenthood and said,

“…I don’t think that we are ready, as a society, let’s say... children are very cruel at such ages and say to another child, ‘I have a daddy and a mummy and you don’t; you have two daddies or two mummies’...”

Concerns related to the role of the transgender parent (low parental self-efficacy)

Several participants showed positive attitudes towards transgender parenthood.

Antonio, a trans man who was between 35 and 45 years old, still in transition, said,

“Whatever love is given, eh... by a straight couple is the same as the love that can be given by a trans person; in essence, eh, love or one’s conduct does not change because of one’s gender identity.”

However, some participants believed that they would not be able to perform parenting tasks successfully. They were afraid of taking responsibility because they were extra cautious about being responsible for someone else and doing things properly.

Luis, a trans man who was between 25 and 35 years old, still in transition as a pansexual, said,

“…It’s a very big responsibility to be responsible for someone else...”

Other participants explicitly expressed their belief that they did not have the qualifications to be a good parent.

Jonathan, a trans man who was between 25 and 35 years old, still in transition, focused on his chronic depression and stated,

“…I don’t believe that I will ever reach the psychological stage of my life when I am going to want to and be capable of raising a child (psychologically); I suffer from chronic depression, and I don’t know how this may affect a child’s life.”

Interestingly, some participants were afraid of becoming parents because they were extra cautious about potential dangers to their children (i.e., due to heredity or the toxicity of the use of hormones to embryos or fetuses).

Below, representative quotes of six participants (the aforementioned Luis and five other participants) related to this subtheme are presented [Additional file 2 (Supplementary Material)].

Concerns about children’s welfare related to a well-established transgender identity

Some participants felt that gaining a clear gender identity implicitly accepted by others is a prerequisite for becoming a transgender parent.

John, a trans man who was between 40 and 50 years old, in social transition, believed that a transgender individual should gain unambiguous social acceptance of his new gender identity before becoming a parent. The participant stated,

“[In the past], I did not think of becoming a father, because… there were people who could not accept [my male name], and I had to fight... I believe that trans parents are also parents, but I think that for [a trans person] to start [the process of becoming a parent], everyone must have accepted this... trans person first.”

The quotes of George related to this subtheme continue below [Additional file 2 (Supplementary Material)].

Concerns about children’s welfare related to the fact that transgender parenthood diverges from heteronormativity (dominant sexual and gender norms)

Importantly (though not surprisingly), the participants perceived their adherence to heteronormative patterns of parenting (traditional parent figures) as their motivation for rejecting same-sex and transgender parenthood. Jessie, a trans woman who was between 45 and 55 years old and had completed the transition process, expressed her strong intuition-based prejudice against same-sex parenthood and stated,

“…I cannot fully ratify this; I may be wrong - should I call myself a racist? I don’t know why, but there is something I don’t like about it; I cannot fully decipher it... I don’t know exactly what it is. Is it being old school?...”

Jenny, a trans woman who was between 45 and 55 years old, in social transition, placed considerable emphasis on naturalness and explained,

“The child is going to see me as I am. What can I tell you? If I were in the child’s place, I would like to have a mum and a dad!... Why should I do this? Isn’t it selfish?... It is a sacred thing, Christina!!! It is not only a social issue but also a matter of nature! How can I explain this to you? To your eyes, what is nicer? A photo with mum, dad, grandpa and grandma or a photo with two transvestites? What can I tell you? What seems nicer to you?”

High-cost treatments and legal framework as barriers

In this study, economic factors such as the cost of the FP procedure and the storage of gametes were also reported as major barriers to transgender parenthood. For example, the participants Fabiola (a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process), Edward (a trans man who was between 30 and 40 years old, at an advanced stage of the transition process), Luis (a trans man who was between 25 and 35 years old, still in transition as a pansexual), and Jenny (a trans woman who was between 45 and 55 years old, in social transition) highlighted this barrier. Moreover, Jessie (a trans woman who was between 45 and 55 years old who had completed the transition process), and Fabiola, (a trans woman who was between 18 and 25 years old, at an advanced stage of the transition process), reported the perceived as less-than-perfect Greek legal framework (as anticipated above) as a barrier to transgender parenthood.

Lack of adequate fertility counseling

One of the problems that transgender people often face related to FP and assisted reproduction is the lack of information. Consistent with past literature, our study findings showed that a significant barrier to pursuing FP and/or assisted reproductive techniques was the lack of counseling about FP options.

Over the last decade, many authors have highlighted the need for vulnerable populations of transgender adolescents and young adults to be provided with fertility counseling prior to the initiation of the gender-affirming care process [ 8 , 9 , 11 , 34 , 35 , 36 ] Footnote 3 . Fertility counseling should be highly prioritized as an ethical, interdisciplinary practice [ 37 , 38 , 39 , 40 , 41 ]. Despite multiple papers being written about the need for this issue to be addressed, almost all the participants in this study felt that FP had not been adequately offered. Previous literature has highlighted that transgender people should be provided with ‘enough information, support and opportunity to make an informed decision about fertility preservation’ [ 8 ] Footnote 4 . Very recently, Sterling and Garcia (2020) argued that a ‘lack of reliable information available from other and outside sources’ is among the most common reasons for the discrepancy between reported high interest in FP and a very low utilization rate [ 20 ] Footnote 5 . The authors stressed that physicians need ‘better training about transgender patients in general, and FP options available to them’ [ 20 ]. Petit, Julien & Chamberland (2018) also stated that physicians must be trained to be aware of transgender persons’ specific challenges and to better support them [ 15 ].

Moreover, it should be highlighted that some children/pubertal children/adolescents/young adults may not yet be mature and competent enough to evaluate, on their own, whether to pursue FP [ 37 ]. Some of the participants described a point at which they should have received information about FP options, even though, due to being a minor at that time, they might have been unable to fully understand either the implications of their reproductive decisions or their future attitudes towards having biological offspring many years later in their lives. This was the case with some participants (Fabiola and Edward). In such scenarios, questions may arise regarding decision-making authority [ 11 ].

Barriers related to discrimination and bullying

Barriers related to discrimination and bullying were one of the frequent themes and encompassed the subthemes of bullying during pregnancy by the general population and bullying by health professionals in birth settings [ 42 ]. Across the globe, transgender people are extremely vulnerable to physical and sexual violence and experience epidemic levels of stigma, discrimination, harassment and social rejection in almost every aspect of their daily lives, including their access to health care services [ 43 , 44 , 45 , 46 ] Footnote 6 . Being a transgender parent is still heavily stigmatized in Greece. Kantsa (2014) argued that ‘normative concepts of kinship …are acquired through a heterosexual marriage ‘blessed’ with children’ [ 27 ]. In addition, the rise of extreme right-wing populism (due to economic crises in both urban and rural areas) that is openly violent and racist seems to be a theme in the Greek political scene [ 47 , 48 ] Footnote 7 .

Our analysis showed that stigma against pregnant trans men can occur in hospitals or midwifery units where pregnant trans men have to go to give birth. This finding is consistent with previous research. Societal attitudes ‘erect barriers to openly being pregnant and giving birth as a transgender man’ [ 13 ] Footnote 8 . Charter et al. (2018) stated that ‘healthcare systems are not generally supportive of trans bodies and identities and trans men encounter significant issues when interacting with healthcare providers’ [ 12 ]. This is consistent with many other studies [ 13 , 18 , 41 , 49 ]. There are institutional barriers to transgender men receiving routine patient-centered perinatal healthcare services [ 13 ]. Trans men who are gestational parents ‘seek to normalize their experiences of conception, while also acknowledging the specific challenges they face’ [ 18 ]. Furthermore, Armuand et al. (2020) found that physicians said that they ‘had little knowledge about the next step following FP as they only had vague knowledge about the transgender men’s reproductive choices and legal rights’ [ 42 ].

Regarding Greece, Giannou (2017) reported that in Greece, transgender people often experience discrimination by healthcare providers, ranging from disrespect or transphobic insults to outright denial of service, when accessing healthcare services [ 24 ]. This discrimination can be seen as a public health issue. Notably, Armuand et al. (2020) found that health care professionals ‘experienced important challenges to their professionalism when their preconceived opinions and values about gender and transgender were confronted’ [ 42 ]. Such challenges may contribute to an unsafe environment for transgender people undergoing FP through various procedures, which may heighten their distress. Health professionals should manage to rethink communication and maintain professionalism when encountering transgender people [ 42 ].

Importantly, according to the narratives of the participants in our study, this prejudice was going ‘underground’ and was being expressed in more subtle, indirect ways. This is not surprising, given the truth of the assumption that anti-homosexual prejudice is no longer exercised in the traditional, ‘old-fashioned’ form (openly related to adherence to ‘naturalness’) but rather in a modern, subtle, ‘nondiscriminative’ form [ 50 ]. Furthermore, in the context of Greece, there may be an additional explanation for this phenomenon. Being a transgender person is stigmatized in Greece, a traditionally conservative country. However, recently, attitudes towards transgender people have become somewhat more positive. Because Law n. 4491/2017 allows citizens to choose to legally change their gender identity (from the age of 15), policy and public opinion have given increased attention to transgender people during the last few years. At any rate, the findings related to discrimination and bullying by health professionals call for efforts by the health service system to provide equal access to fertility and reproductive health services for transgender people. Armuand et al. (2017) argued that health professionals can ‘alleviate distress by using gender-neutral language and the preferred pronoun’ [ 51 ] . Riggs & Bartholomaeus (2020) highlighted the need for ‘the continued development of trans reproductive justice’ [ 16 ].

FP and/or IVF may worsen dysphoria and delay effective transitioning

The impact of FP and/or IVF on the worsening of dysphoria and the delay of effective transitioning was a significant theme. Consistent with past literature, we found that among transgender people, there are unique barriers to FP related to gender dysphoria. Transgender adolescents face several obstacles that affect fertility decision-making [ 36 , 37 ], including the invasiveness of procedures, individual experiences of gender dysphoria, and a desire not to delay the gender-affirming transition [ 36 , 52 ]. De Sutter et al. (2002) found that while the vast majority of respondents thought that FP should be offered to transgender women, 90% of respondents believed that the loss of fertility was not a strong reason to delay the transition [ 53 ]. This is consistent with the statement of Chiniara et al. (2019) presented below in footnote [ 54 ].

Chen and Simons (2018) effectively explained that ‘transgender adolescents pursuing hormones may be at particularly high risk for prioritizing short- versus long-term outcomes, putting them in jeopardy for later experiencing regret’ [ 6 ]. Importantly, FP methods ‘might reinforce transgenders’ previous sex or make them feel it does not fit with their new gender identity’ [ 11 ]. Interestingly, procedures required for FP (i.e., hormonal ovarian stimulation and transvaginal ultrasound, which is a genitalia-specific procedure) may be experienced by trans men as having the negative impact of worsening their gender dysphoria [ 51 ]. These procedures may heighten feelings of dysphoria, thus challenging transgender people’s break with their old gender identity. Note, however, that this is not always the case [ 51 ].

This may partly explain the reluctance of trans men to become pregnant. Nahata et al. (2017) argued that ‘more research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood’ [ 55 ]. This was a significant theme that emerged from our data analysis because there were a large number of comments related to this category, and considerable emphasis was placed on this topic by the participants in our study. However, it is crucial to bear in mind that ‘presently little is known about the psychological effects of FP for transsexuals’ [ 11 ], and the number of related studies is still limited.

Furthermore, transgender people’s break with their old gender identity may be challenged by the fact that it cannot be ruled out that future children will be informed about their parent(s)’ status as transgender persons [ 11 ]. It is noteworthy to mention that none of the participants raised concerns about such problems.

Moreover, we found that the highly symbolic value of pregnancy is likely a barrier to FP and assisted reproduction for individuals undergoing female-to-male gender-affirming transitions. Given that pregnancy is considered to be strictly related to femininity, it may negatively affect a trans man’s gender transition by challenging his break with the old (female) gender identity. However, this is not always the case. It is argued that trans men use contraception and can experience pregnancy, even after having transitioned socially, medically, or both [ 14 , 56 ]. Moreover, notably, one participant explained that the symbolic value of the uterus may effectively facilitate the gender tradition process, most likely based on the common acceptance that pregnancy is a women’s affair and strongly related to femininity. The participant said that a uterus transplant at a younger age (if possible) would make her feel 100% a woman. The phenomenologist Svenaeus (2012), analyzing the changes in identity and selfhood experienced through organ transplantation, stated that ‘…the organ in question is taken to harbor the identity of another person, because of its symbolic qualities…’ [ 57 ] Footnote 9 . Not surprisingly, a trans woman may desire to have the woman-specific experience of gestation. However, such a right might be controversial [ 58 , 59 ].

Trans men may be more likely to become parents after gender transition [ 7 ]. Some transgender men retain their uterus [ 13 ]. Some participants (trans men) were explicitly willing to donate their oocytes and become genetic parents. Interestingly, we found that a trans man in social transition was much more willing to donate gametes (oocytes) than many other participants. His strong willingness may have been partly because he was not in a gender-affirming transition but in a social transition. Many trans men participants in our study touched upon some aspect of oocyte cryopreservation. It is of great importance that little is known about transgender men’s experience with FP procedures such as cryopreservation of oocytes due to a lack of previous empirical research on this topic [ 51 ]. Recently, a study found that ‘adolescent transgender males who choose to undergo oocyte cryopreservation tolerate the process well’ [ 60 ]. The aforementioned findings of our study gave us the opportunity to formulate starting points for further research. These points are presented below in the section ‘ Implications for practice and further research ’.

Placing considerable value on genetic relatedness motivates transgender people to have the willingness to become biological parents

Involuntary childlessness is associated with serious negative psychological effects: serious anxiety and stress, feelings of grief, social isolation, low self-esteem, and sexual dysfunction [ 61 , 62 , 63 ]. Furthermore, according to a holistic positive concept of health, involuntary childlessness can be regarded as an unhealthy situation.

Reproductive desire was high among the majority of the participants in the present study. Notably, however, this view may be a result of mechanisms such as ex post realization or the overgeneralization of hard-wired perceptions due to low self-esteem (which, in turn, may be due to internalized anti-trans prejudice). Further studies are needed to assess whether internalized anti-trans prejudice is associated with a weak desire among transgender people to have a child to whom they are genetically related or to an unwillingness to have children.

Prior studies have suggested that reproductive desire is as high among transgender people as it is in the general population [ 35 , 40 , 53 ]. Among transgender adolescents, the utilization rates of FP and reproductive options are currently very low [ 10 , 55 ] but steadily rising [ 11 , 35 ]. In 2012, it was argued that ‘research on transgender adults suggests that about half desire biological children…, and over a third would have considered FP had such technologies been available at the time of their transition’ [ 35 ]. In our small sample, this percentage was much greater. The lack of adequate FP counseling may partly explain these low rates [ 10 ]. Riggs and Bartholomaeus (2018) argued that FP should be made available to all transgender people before they undergo gender transition treatment that could negatively affect their future fertility, although not all transgender persons would be willing to undertake FP [ 17 ]. Nevertheless, this topic seems to be complex [ 54 , 55 , 64 , 65 ] Footnote 10 .

Barriers related to parenting and the child’s welfare

Barriers related to parenting and the child’s welfare were a frequently recurring theme in our interview data analysis, and several participants in our study identified such barriers. There were various types of reported barriers, and they can be categorized into the following three subthemes:

Barriers related to the social environment (prejudice against children of transgender parents)

Transgender people’s children are vulnerable to discrimination and bullying. Although the best currently available evidence does not support the notion that there are inherent risks to the welfare of the child of a transgender person, there may be external risks to the welfare of the child based on social discrimination and stigma [ 11 ]. Having children is strongly related to heteronormative stereotypes.

Barriers related to transgender parents’ perceived limited parenting capability

The majority of the participants in our study felt incapable of meeting the standards of adequate parenting or perceived themselves as potentially harmful to their children. From the analysis of their statements and their corresponding nonverbal behavior patterns, we sensed that they drew unfair conclusions about their parental capacity based on low self-esteem. Internalized transphobia may negatively impact self-esteem [ 66 ] and hence limit transgender people’s (reproductive) autonomy [ 67 ], and this may be the real reason behind the unwillingness of transgender people to become parents. Transgender individuals’ parental role is a complex issue. Petit et al. (2017) stated that ‘…trans parental identity appeared as a multidimensional, multidetermined, nonbinary, and fluid identity in a context of nonalignment between the sex assigned at birth and gender identity’ [ 68 ]. This nonalignment may heighten feelings of parental incapacity.

Barriers related to transgender individuals’ values (adherence to patterns of the dominant culture)

According to the findings of the present study, transgender individuals may have both new and old understandings of patterns related to parenthood, such as biological relatedness and parenting figures. This finding is consistent with past literature on issues of LGBT parenthood [ 69 ].

In conclusion, several of the aforementioned findings in the ‘ Concerns related to transgender parenting and children’s welfare as barriers ’ section of the paper suggest that some transgender people have very low expectations about what kind of parents they would become; that is, they have low parental self-efficacy. Moreover, it is worth noting that we identified several subthemes grouped under the theme ‘concerns related to child welfare’. In our opinion, the presence of several subthemes for this supports the assumption that transgender parenthood is a complex, complicated, and multidimensional issue.

Barriers related to economic instability

The costs of FP are a significant barrier because these procedures are typically not covered by insurance companies [ 37 ]. Transgender people are particularly vulnerable to economic instability due to their high unemployment rate related to the mere fact of being transgender. Riggs and Bartholomaeus (2018) argued that while ‘fertility preservation should be made available as an option to all transgender or nonbinary people prior to undertaking treatment which may impact on fertility’, ‘not all people may be able to afford to’ [ 17 ]. Very recently, Sterling and Garcia (2020) suggested that ‘the considerable out-of-pocket costs’ may be one of the common reasons why, despite a reported high level of interest among transgender persons in FP, there was a very low utilization rate [ 20 ]. Furthermore, it should be noted that there are still high unemployment rates in Greece due to the Greek financial crisis.

Strengths and limitations

This research is important in that to our knowledge, it is the first to directly examine transgender people’s attitudes towards the use of FP options or assisted reproductive techniques in Greece.

However, our study has two primary limitations. First, our findings cannot readily be generalized to larger populations because of the small number of participants. However, the findings of this study might be applicable to other transgender people. While qualitative studies may sometimes be criticized for their limited generalizability due to small samples, in our opinion, they remain valuable as indicators of the range of views within the public and how these views may be influenced. Second, the participants in this study reflected on their past experiences, which, for some, had occurred more than 10 years prior to being interviewed. Recall bias may have distorted the recollections of their experiences considering FP options or assisted reproductive techniques. To minimize recall bias, we attempted to establish a climate that would enable the participants to recall their lived experiences and events that occurred many years before as it related to having a child to whom they are genetically related and to pursuing fertility treatments. Moreover, we spent more time with older participants to help them return to their youth when they had reproductive options. We provide more details in the limitations section.

Implications for practice and further research

The results of our analysis of the study data may have implications for both research and clinical practice. These results could provide guidance for professionals processing transgender people’s applications for medically assisted reproduction and FP. We highlight the need for training for health professionals to establish a safe environment for transgender people who are willing to pursue FP or IVF, especially in places (in both urban and rural areas) where there is a high prevalence of extreme right-wing populism in the context of the Greek economic crisis.

Moreover, we emphasize that rigorous psychological evaluation is required. Careful, in-depth psychological evaluation would provide important information for understanding the primary reason behind a transgender individual’s attitude towards fertility matters. In the short time frame of the interview, Patrick, a trans man who was between 25 and 35 years old and had completed the transition process, reported four reasons for his unwillingness to consider FP options or assisted reproductive techniques. The participant provided a basis for the assumption that these reasons (mentioned elsewhere in this paper) are equally strong. For instance, the participant’s attitude might have resulted from mechanisms such as ex post realization or overgeneralization of hard-wired perceptions.

At any rate, our findings could heighten awareness of and stimulate debates about the ethical topics related to our research questions.

Furthermore, based on the findings of our study, we provide some starting points for further research. For instance, the association between the type of transition and the willingness to become involved in procreation remains to be tested. Moreover, it remains to be further explored whether transgender individuals who are in social transition show greater adherence to the dominant culture than those in gender-affirming transition, at least in the context of reproduction. Last, we stress the need for further empirical research into transgender men’s experience of FP procedures such as the cryopreservation of oocytes. In this vein, it would be interesting to investigate whether transgender people should be classified as a separate group of the LGBT community and whether data on transgender individuals should be analyzed separately.

The results demonstrate the importance of both contextual factors (stigma, economic instability, and law) and factors related to transgender people themselves (gender dysphoria, the desire to become parents, and self-trust). More specifically, the conducted analysis resulted in the identification of the following themes that represent key barriers to pursuing FP or ART: lack of fertility counseling; high costs and economic instability (due to the Greek economic crisis); concerns related to the child’s welfare due to factors related to the context or transgender people themselves; a less-than-perfect legal framework on transgender people’s rights; concerns about whether fertility treatment may negatively impact the gender transition process; fears of discrimination (by the general population or even health care providers); and fears of bullying in the traditionally conservative Greek societal system, which embraces heteronormativity and is gradually emerging from a decade-long economic crisis that gave rise to extreme far-right populism. A number of subthemes were grouped under the primary themes. Various reasons behind the transgender participants’ varying degrees of desire for parenthood were identified. Furthermore, the results indicated the symbolic role of the uterus (important to trans women) and pregnancy-related body changes (important to trans men, as they act as a barrier to the gender transition process and give rise to discrimination against them). The results allowed us to hypothesize that transgender individuals in social transition are much more willing to pursue FP or ART (or, for trans men, to become pregnant) than those in gender-affirming transition. In addition, transgender individuals showed striking adherence to patterns of the dominant culture in regard to attitudes towards having children and low self-esteem.

Transgender people’s willingness to pursue FP and/or IVF is a complex topic, and we highlight the need for rigorous individual psychological evaluation. Moreover, we stress the need to train health professionals to establish a safe environment for transgender people who want to undergo fertility treatment, become pregnant and give birth. Health professionals should be trained to develop trans reproductive justice.

The findings of this study call for efforts by the fertility and reproductive health service system to support and provide equal access to fertility and reproduction-related services for transgender people. Addressing the barriers to transgender parenthood that are documented in this article will require policy initiatives and a social justice approach towards transgender individuals’ health and human rights. Health providers can play a crucial role in this process. Therefore, the need to establish standardized protocols and provide necessary training to physicians is highlighted.

Availability of data and materials

The transcripts of the full interviews that were collected and qualitatively analyzed in the current study are not available due to the ease with which study participants could be identified. The redacted transcripts used and analyzed during the current study can be made available by the corresponding author on reasonable request.

The term ‘transition’ is used to refer to all types of gender-affirming (endocrine or surgical) transitions. The term ‘social transition’ is used to specifically reflect gender transition. The participants in ‘social transition’ opted not to undergo gender-affirming treatment, believing that a change in their gender role or behavior would itself be sufficient.

At the time of the interview, ‘still being in transition’ was ‘being on the road to what the particular participant perceived as full transition’.

In 2012, Wierckx et al. remarked that transgender people’s fertility issues were not adequately addressed [ 35 ]. This observation still applies in the present day. Chen et al. (2019) found shortcomings in fertility counseling and providers who highlighted the need for standardized counseling protocols [ 36 ]. Interestingly, their findings indicated that transgender people could later regret not pursuing FP despite having previously received FP counseling.

Murphy (2012) argued that there is nothing objectionable that would justify removing parenting options for transgender people [ 39 ]. The American Society for Reproductive Medicine (ASRM, 2015) stated that “transgender persons have the same interests as other persons in having children” and that “providers should offer FP options to individuals before gender transition” [ 40 ]. The Ethics Committee of the American Society for Reproductive Medicine stated that transgender people’s gender identity cannot be grounds for unequal treatment and that professional autonomy is not a sufficiently strong countervailing reason to justify an exemption. Transgender people should be provided with ‘enough information, support and opportunity to make an informed decision about fertility preservation’, and the discussion should include ‘a consideration of interweaving factors, particularly costs…’ [ 8 ]. ‘Detailed information about every option in the absence of any form of coercion and with ample time is essential for a person to make complex, life-changing decisions’. [ 38 ]. The importance of genetic relatedness might be used as a ‘heuristic through which to provide fertility counseling to transgender people’ [ 41 ]. From the perspective of transgender people’s fertility counseling, health professionals communicate with transgender people about desires related to reproduction [ 9 ]. Furthermore, transgender people should be informed that ‘FP methods do not guarantee future access to medically assisted reproduction (due to the best evidence then available, i.e., concerning the child’s welfare) or successful reproduction’ [ 11 ].

Notably, however, that discrepancy may (partly) be because physicians feel most uncomfortable talking about transgender planned parenthood. Sterling and Garcia (2020) argued, ‘Transgender patients report using assistive reproductive services difficult, due to a lack of dialogue about fertility and the lack of information offered to them- presumably because their circumstances do not fit into a traditional narrative familiar to providers’ [ 20 ].

In Europe, the European Union Agency for Fundamental Rights (2014) reported that approximately 20% of all trans respondents who accessed healthcare services or social services reported that they had experienced discrimination for the same reason [ 43 ]. In Australia, although in 2013 the Sex Discrimination Act was amended, transgender individuals still experience discrimination and barriers to access to health care services [ 44 ]. Much of the same holds for Asia [ 45 ] as well as for Latin America and the Caribbean [ 46 ].

Therefore, according to many participants, the fear of violence against pregnant trans men or transgender parents was greater in urban areas (with a high percentage of extreme right-wing populism), although normally urban areas are more tolerant, open-minded, multicultural and less conservative and traditional than small towns or villages (provinces or rural areas).

A Canadian interview study found that transgender men face considerable discrimination throughout their pregnancy [ 49 ]. Riggs (2013) found that transgender men who go through a pregnancy negotiate complex intersections between their masculinity and child bearing, with their pregnant bodies being regarded by health care providers as female [ 41 ].

Notably, however, Robertson (2017) argued that procreative liberty only supports a right to gestate when gestation is sought for genetic reproduction, and hence, the claim of a transgender woman desiring a uterus transplant to have the woman-specific experience of gestation is not strong enough to undergird a positive right [ 58 ]. Notwithstanding, Alghrani (2018) argued that procreative liberty does extend to a right to gestate [ 59 ].

A U.S. study found that only two of 72 transgender young people receiving fertility counseling prior to endocrine transition attempted FP [ 55 ], while a recent study with a Dutch cohort of trans girls found a much greater percentage attempting FP [ 64 ]. Persky et al. (2020) found that the majority of transgender youth were not willing to delay their hormonal transition for FP, as they ‘did not find having biological offspring important’ [ 65 ]. Chiniara et al. (2019) arguably hypothesized that fertility may be a low life priority for young transgender people. ‘The majority wish to become parents but are open to alternative strategies for building a family’ [ 54 ].

Abbreviations

Fertility preservation

Assisted reproductive technology

In vitro fertilization

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We would like to wholeheartedly thank all transgender persons who offered their insightful input as participants in this investigation.

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PV was responsible for the study conception, data analyses, ethical analysis of the findings, writing of the paper and reporting of the study. C-EZ interacted with the participants and performed the interviews, transcriptions, translations and initial analysis. M-VK and PP assisted in the data analysis and revisions of the paper. All authors have read and approved the final manuscript.

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Voultsos, P., Zymvragou, CE., Karakasi, MV. et al. A qualitative study examining transgender people’s attitudes towards having a child to whom they are genetically related and pursuing fertility treatments in Greece. BMC Public Health 21 , 378 (2021). https://doi.org/10.1186/s12889-021-10422-7

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2 July 2024

Research led by Dr David Galley, Course Leader Social Work at Solent University, Southampton, addresses the sparsity of male practitioners in the female majority profession and argues for an increased range of gender balance, to be more representative of the communities it serves.

New research identifies the barriers for males qualifying as social workers and determines action to attain increasing gender balance in the profession.
Recommendations on the recruitment of males to social work include focusing on where they might be drawn from and more career guidance in secondary and further education.
The paper suggests the status of a social worker plays a role in the number of males in the profession and makes recommendations in raising its status.

Published by the British Journal of Social Work, 'Male social work students: common dispositions, motivations, experiences and barriers impacting their career choice' offers new insights into the gender balance of social workers in the UK.

Dr Galley worked with male social work students by utilising surveys, field observations, semi-structured interviews and the Bem sex role inventory test – which is used to measure an individual’s femininity and masculinity – to understand both what draws and repels males from the profession.

In June 2024, Dr Galley gave an address on the study at the Joint Universities Social Work Association Conference 2024, held at Kingston University, London. His talk focused on one of the conference’s key themes: building relationships and networks that support social solidarity and global connectedness.

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Unfolding the empathic insights and tendencies among medical students of two gulf institutions using interpersonal reactivity index

Haniya Habib 1 ,
Sara Anjum Niinuma 1 ,
Khadeja Alrefaie 1 ,
Heba Awad Al Khalaf 2 ,
Mohammad Jasem Hani 2 ,
Zeinab Yaareb Mosleh Al-Rawi 2 ,
Zarish Hussain 1 ,
Prianna Menezes 1 ,
Sornali Rani Roy 3 ,
Bincy Mathew 1 ,
Salman Yousuf Guraya 2 ,
Alfred Nicholson 1 &
Shaista Salman Guraya 4

BMC Medical Education volume 24 , Article number: 976 ( 2024 ) Cite this article

Metrics details

Empathy is an essential core competency for future doctors. Unfortunately, the medical curriculum is infamously known to burn out aspiring doctors, which may potentially lead to a decline in empathy among medical students. This research was planned to understand the evolution of empathic approaches among students across the curriculum using the Interpersonal reactivity index (IRI) as a benchmark at the Royal College of Surgeons in Ireland - Medical University of Bahrain (RCSI-MUB) and University of Sharjah (UoS).

We adopted a cross-sectional design and administered an online survey to the medical students of RCSI-MUB and UoS using a modified version of the IRI along with its three subscales of empathic concern (EC), perspective taking (PT), and personal distress (PD). To identify intra- and inter-institutional variations in empathy scores, the Analysis of Variance (ANOVA) was performed separately for each institution and with both institutions combined. A two-way ANOVA was conducted for the comparison between years and institutions. For the subscale analysis of EC, PT, and PD, we used one-way ANOVA for significant differences between years at both institutions. For the gender-effect analysis, t-test was performed to examine the differences in total IRI scores at both institutions combined and at each institution separately. Additionally, an Analysis of Covariance (ANCOVA) was done to identify the influence of gender on empathy scores.

A total of 140 students from both institutions participated in this study. We found a fluctuating pattern of empathy scores without a clear trend across the years. The sub-scales of EC, PD, and PT across academic years at both institutions showed significant differences within the EC at RCSI-MUB ( p = 0.003). No significant differences were identified across other years from both institutions. There were significant differences between empathy scores from RCSI-MUB and UoS for EC ( p = 0.011). Additionally, a pronounced interaction effect between year and institution was observed for PT ( p = 0.032). The gender-wise analysis showed that female students had higher empathy scores than males ( p = 0.004). The ANCOVA for IRI score results revealed a p -value of 0.023, indicating that gender plays a crucial role in empathy levels among medical students. The ANCOVA results revealed a p -value of 0.022 in the EC subscale.

Our study unveiled intricate patterns in empathy development among medical students across years and genders at RCSI-MUB and UoS. These congruences and dissimilarities in empathy scores signal a subjective understanding of empathy by medical students. The disparities in understanding may encourage medical educators to embed empathy in standard medical curricula for better healthcare outcomes.

Peer Review reports

In modern healthcare systems, empathy is considered as a fundamental pillar that plays a pivotal role in fostering patient trust, improving patient outcomes, and enhancing patient satisfaction [ 1 ]. Additionally, empathy allows physicians to communicate effectively with their patients and to express their humanistic and compassionate attitude [ 2 ]. Empathy pertains to the ability to perceive, recognize, and share another person’s feelings [ 3 ]. An empathic approach by physicians enhances physician-patient relationships, patient safety, and healthcare outcomes due to improved patient compliance and understanding of management plans [ 4 ]. Despite its outright benefits in the medical field, empathy needs to be better nurtured and understood in medical schools. A multitude of factors may contribute to this poor understanding of empathy, including a lack of a standard definition of empathy and consistency in the delivery and assessment of its cognitive, affective, and behavioral parts [ 5 ]. Furthermore, research has found that social commitment to medicine, including empathy, declines as students’ progress through their studies [ 6 ]. The medical curriculum is infamously known to burn out aspiring doctors, and consequently, their ethical values rapidly decrease, particularly during clinical years [ 7 ]. This is perhaps an aftermath of less emotional involvement of medical students with patients. [ 8 ].

In the context of patient care, a clear distinction between cognitive empathy, defined from a knowledge perspective (involving understanding processes), and empathy, defined from an emotional perspective (involving feelings and affect), is very crucial. These two forms of engagement yield different outcomes [ 9 ]. This emotional attunement of physicians fulfills the cognitive purpose of apprehending and sharing patients’ feelings and sufferings. Having a surplus of cognitive empathy (also known as clinical empathy) in patient care is consistently advantageous and can lead to the development of trust-based relationships, more precise diagnoses, enhanced patient compliance, and consequently, more favorable patient outcomes [ 10 , 11 ]. However, an excess of emotional involvement, also known as sympathy, can be detrimental to patient care, resulting in emotional exhaustion and professional burnout among healthcare providers and unchecked emotional reliance on the part of the patient [ 12 , 13 ]. Uncontrolled emotions can readily interfere with the objective process of making clinical decisions [ 14 ].

Empathy is contextually contingent and primarily shaped by situational factors and one’s inherent empathic tendencies [ 15 ]. These inherent tendencies can impact both cognitive and affective empathy. Individuals with high inherent empathic tendencies may better understand and appreciate others’ perspectives and emotions, complementing their cognitive empathy [ 16 ]. In medical education, understanding the inherent empathic tendencies of undergraduate medical students can provide valuable information to provide implications for their future patient care practices and interactions. In unison, such natural inclination towards emotional resonance can foster affective empathy, enabling one to genuinely share in the emotional experiences of others and respond compassionately [ 17 ]. Therefore, inherent empathic tendencies are integral to an individual’s overall empathic disposition, influencing how they connect with and understand the feelings and perspectives of those around them.

To date, numerous studies have explored the progression of empathy among medical students using various measurement scales, including the Interpersonal Reactivity Index (IRI) [ 18 , 19 , 20 , 21 , 22 ]. However, most of these studies have primarily focused on institutions in North America and Asia, with limited research conducted in the Middle Eastern region. It’s crucial to acknowledge that cultural nuances influence empathy, and therefore, findings from studies conducted in one cultural context may not necessarily generalize to medical institutions in other settings. This underscores the importance of conducting research in diverse cultural contexts to better understand the complexities of empathy development among medical students globally.

By investigating the empathic tendencies of medical students using the Interpersonal Reactivity Index (IRI) from two Middle Eastern institutions, we aim to shed light on the interplay of the complex relationship between innate empathy and external factors (educational environment), ultimately contributing to a more comprehensive understanding of empathy in medical education. By administering the IRI questionnaire, we aim to investigate the variations in empathic tendencies between these two groups of medical students, including perspective-taking (PT), empathic concern (EC), and personal distress (PD). PT measures the ability to shift to another person’s perspective, EC measures other-oriented feelings of sympathy and concern for others, and PD measures self-oriented feelings of personal anxiety and uneasiness in tense interpersonal settings. Additionally, this research seeks to identify potential factors or associations that may influence empathy scores within the context of medical education and institutional differences at the Royal College of Surgeons in Ireland, Medical University of Bahrain (RCSI-MUB) and the University of Sharjah (UoS) in the United Arab Emirates (UAE).

Our research delved into the evolution of the empathic approaches among medical students of two distinct academic institutions in the Middle Eastern region. The primary research question of our study was to determine the pattern of empathic insights of medical students across certain time points of their medical curriculum. A secondary end-point outcome was to compare yearly, gender-wise, and institutional variations in the understanding of medical students’ empathy between both institutions.

Materials and methods

The Bachelor of Medicine and Bachelor of Surgery (MBBS) programs of RCSI-MUB and UoS contain a foundation year and a 5-year program with three phases of basic medical sciences, pre-clinical, and clinical sciences. Empathy is not delivered as a stand-alone subject in both institutions; however, it is arbitrarily covered during the clinical training of medical students. Between March and June 2023, an email invitation was sent to the undergraduate medical students of RCSI-MUB and UoS studying in foundation year till year 5. The invitation included details of the research study, a participant information leaflet (PIL), and a consent form. The registered students received another email with PIL and a SurveyMonkey questionnaire. Participants were requested to abide by the regulations for data privacy and their institutional codes of professional conduct throughout the study.

The study’s target population was undergraduate medical students who were currently studying foundation year till year 5 of study. A purposive sampling method was used to recruit medical students, and a convenience sample was obtained by approaching the participants who were available at the time of data collection. We invited student representatives from each year and institution to provide their perceptions of the IRI questionnaire. In total, we invited 144 student representatives from foundation to year 5 of both institutions, around 24 students from each year. Of those, 140 participated in our study with a response rate of 97%.

Empathy measuring tools

An online survey was conducted using a modified version of the IRI, a widely recognized instrument for gauging empathy with a subset of scales and relevant tools [ 23 ]. This index was used for this study since it is the most widely used self-report measure for empathic tendencies due to its multidimensional approach and comprehensive assessment of empathic dispositions [ 24 , 25 ]. Its validity and ease of administration are why we selected it for our study to assess empathic tendencies. The questionnaire also collected demographic data of student initials, gender, and year of study. We utilized the modified version of IRI, where we evaluated three of its four subscales: PT, EC, and PD, which contribute to cognitive and affective empathy [ 26 ] (Appendix I ). PT, encompassing the cognitive aspect of empathy, delineates one’s capacity to understand and adopt another person’s viewpoint, thoughts, and feelings. On the other hand, EC is associated with affective empathy, encompassing the emotional resonance and compassionate response one feels in response to another person’s emotional distress or suffering. PD within the IRI pertains to an individual’s own discomfort and unease when confronted with the suffering of others, which can hinder empathic responses. Therefore, the IRI’s dimensions help dissect the intricate interplay between cognitive and affective empathy, shedding light on the multifaceted nature of empathic experiences. For the context of our study, we excluded the fantasy subscale, considering it less relevant to the medical milieu. The participants were instructed to answer on a 5-point scale of A-E ranging from ‘does not describe me well,’ ‘neutral’ to ‘does describe me well.’ Each subscale enquired about the participants’ insights on different empathic dispositions. A high score on PT indicates a tendency to adopt another’s psychological perspective, while a high score on EC shows a tendency to experience feelings of warmth, sympathy, and concern toward others. Finally, a high score on PD demonstrates a tendency towards feelings of discomfort when witnessing others’ negative experiences.

Statistical analysis

Total iri score analysis.

Initially, we conducted an analysis of the total IRI scores across all participants from both institutions, stratified by academic year (foundation to year 5). This comprehensive approach provided an overarching insight into the empathic tendencies of students at different stages in their academic journey. Descriptive statistics, including mean and standard deviation, were calculated for each year group, offering a preliminary understanding of each cohort’s data distribution and central tendency. A One-way Analysis of Variance (ANOVA) was performed separately for each institution and with both institutions combined to discern whether significant differences in empathy levels existed between various years’ groups. This step was crucial for identifying intra- and inter-institution variations in empathy scores. Furthermore, a Two-Way ANOVA was conducted with ‘year’ and ‘institution’ as factors to elucidate any interaction effects between the academic year and the institution to determine whether institutions had differential impacts on students’ empathy levels across the years.

Sub-scale analysis

Subsequently, we delved deeper into the individual sub-scales of the IRI (PT, PD, and EC) to dissect the components of empathy exhibited by students. Descriptive statistics for each sub-scale were computed for every year group at each institution, laying the groundwork for understanding the specific empathic tendencies prevalent in each cohort. One-Way ANOVA tests were employed for each sub-scale to probe for significant differences between years at both institutions. This granular analysis was important for unmasking the nuances of empathic development among students. Notably, since a significant variance was detected in the EC sub-scale at RCSI-MUB, post-hoc tests were executed exclusively for this group to identify any differences in insights about empathy. Additionally, Two-Way ANOVA tests were conducted for each sub-scale with ‘year’ and ‘institution’ as factors, facilitating a comparative analysis between the two institutions while considering the interaction effects.

Gender effect analysis

To investigate the influence of gender on empathy, we calculated the mean and standard deviation of total IRI scores for each gender at both institutions. T-tests were performed to examine the differences in total IRI scores between genders at both institutions combined and the total scores of each sub-scale at each institution separately. The rationale for selecting the t-test was its suitability for comparing the means of two groups (male and female students). This step was essential for validating the gender effect on empathy levels, offering a lens through which the data could be interpreted from a gender perspective. Lastly, we included an Analysis of Covariance (ANCOVA). This was conducted to control the potential confounding effect of gender on empathy scores. ANCOVA was applied to the combined data from both institutions, integrating gender as a covariate. This step was crucial to discern if the observed variations in empathy scores, both in total IRI and its subscales (PT, PD, and EC), could be attributed to gender differences among student cohorts.

Ethics approval

The study was approved by the relevant Institutional Research Ethical Committees of RCSI-MUB (REC/2023/147/18-Jan-2023) and UoS (REC-23-03-12-01-F). All participants gave fully informed written consent to participate at the start of the study.

Influence of year and institution

A total of 140 medical students from RCSI-MUB and UoS responded to the online questionnaire in our study. There were 89 female and 51 male students. The yearly distribution of IRI and three sub-scales scores for all participating students from both institutions is presented in Table 1 . This table illustrates the mean, median, standard deviation, and standard error of the total IRI scores and does not apply statistical tests to these values. Observationally, the data show a fluctuating but consistent pattern in empathy scores across the years without marked differences.

Figure 1 a and b, and 1 c display the bar plots of mean scores for the EC, PD, and PT sub-scales, respectively, for students at RCSI-MUB and UoS across different academic years. The results of the One-Way ANOVA for all three IRI sub-scales across the academic years at both institutions showed significant differences within the EC sub-scale at RCSI-MUB ( p = 0.003), as detailed in Table 2 . Subsequently, the Tukey post-hoc test results, demonstrated in Table 3 , show a significant pairwise difference in EC between Year 1 and Year 4 students at RCSI-MUB ( p = 0.035). No significant differences were identified in comparison to other years from both institutions.

Bar plot based on descriptive data with mean scores for empathic concern ( a ), personal distress ( b ), and perspective taking ( c )

Table 4 outlines the results of Two-Way ANOVA tests with significant differences between the insights of medical students from RCSI-MUB and UoS for EC ( p = 0.011, Table 4 ). This implies that the educational environment or the mode of curricular delivery might exert a tangible influence on students’ empathic concerns. Additionally, a pronounced interaction effect between year and institution was observed for PT ( p = 0.032, Table 4 ). An interesting analysis of the responses by medical students from RCSI-MUB and UoS for the subscale PT illustrates a unique pattern of the development of an empathic approach across different year groups (Fig. 2 ). Briefly, Fig. 2 displays the PT scores for foundation year students of RCSI-MUB students who exhibited higher scores than UoS. The PT scores of year 1 students at both institutions increased; however, a divergence was observed in year 2, with RCSI-MUB scores declining while UoS scores continued to increase. In year 3, the scores converged, with both institutions showing similar levels. Year 4 had a reversal, with RCSI-MUB scores increasing and UoS scores declining. Finally, in year 5, RCSI-MUB scores decreased while UoS scores escalated.

A plot diagram with the interaction effect between years and institution for perspective taking ( N = 140)

Gender-specific findings

Table 5 shows the percentages of male and female students across different years at RCSI-MUB and UoS and the overall gender distribution by institution. Table 6 compares the mean IRI scores for female and male medical students from RCSI-MUB and UoS using a t-test. The results showed that female students had higher overall empathy scores than males ( p = 0.004). The gender-wise comparison of scores among medical students for EC, PD, and PT showed a significantly higher empathic concern by female students of RCSI-MUB than their male counterparts ( p = 0.014), as shown in Table 7 . This finding might have been influenced by the fact that all year 1 students at RCSI-MUB were females, potentially affecting the observed gender disparities. Table 8 outlines the ANCOVA for IRI results, which revealed a significant p -value of 0.023, which is below the conventional alpha level of 0.05, and ANCOVA for EC subscale shows a p -value of 0.022, affirming the impact of gender on empathy development.

The findings of our study offer a nuanced perspective on the trajectory of empathy development among medical students, reflecting a deeper understanding of empathy. Though there were insignificant differences for three subscales of IRI for each institution, there was a recognizable variation in EC scores and a fluctuating pattern of responses to PT between RCSI-MUB and UoS medical students. These results underscore the evolving nature of understanding empathy, that may be partly due to an absence of a standardized and accredited empathy-based curriculum. Lastly, female students had a significantly better understanding of EC, which signals a gender-based preference toward empathic care of patients.

These findings are consistent with the notion that empathy is not a static trait but rather a dynamic quality that evolves over time and can be influenced by various factors. In their cross-sectional and longitudinal mixed-methods study on undergraduate and graduate medical students, Michael et al., have deduced that targeted educational programmes should be introduced to develop empathic and patient-centered skills and competence of physicians [ 27 ]. Similar to other studies, our research also showed variations in responses and understanding of medical students in the absence of standard teaching of empathy in the curricula of both RCSI-MUB and UoS [ 28 , 29 , 30 ]. At the same time, we found yearly, gender, and institutional variations in understanding of empathy. The trends in PT scores suggested several points of consideration. The higher initial PT scores of foundation year students at RCSI-MUB compared to UoS may reflect differences in admission criteria, foundational training, or student characteristics between the two institutions. The shared increase in year 1 might indicate a common emphasis on developing perspective-taking skills early in medical education. The divergence in year 2, convergence in year 3, and subsequent variations may be indicative of differences in curricular focus, educational experiences, or other institutional factors that influence the development of perspective-taking skills at RCSI-MUB and UoS. The reversal in year 4 and the final intersection in year 5 may highlight variations in the later stages of medical training at each institution, potentially influenced by different clinical exposures or preparation for professional practice. These observed trends warrant further investigations to understand fully the factors contributing to the development of PT skills at medical academic institutions [ 31 ].

The identified significant variations within the EC sub-scale, particularly at RCSI-MUB between year 1 and 4 students, are particularly noteworthy. While the exact reasons for these variations require further exploration, these findings may indicate the uniqueness of the empathic development trajectory between years 1 and 4. Studies on empathy concerns among medical students report inconsistent data as they may decline, remain stable, or enhance [ 32 , 33 ]. Piumatti et al. witnessed that empathy remains stable in most medical students and declines in fewer [ 34 ]. Furthermore, the authors observed that freedom to talk and patient-centric motives for studying medicine were associated with a higher and consistent empathic approach. The differences in EC scores among students of both institutions might indicate variations in educational environment or curriculum or both. Further research is essential to interpret the implications of these findings fully and understand the factors contributing to the observed differences in EC scores among medical students at RCSI-MUB and UoS.

The significant interaction effect between year and institution for PT suggests that the journey of empathy development is not linear and is influenced by a myriad of factors, including the educational environment. The gender differences observed, especially within RCSI-MUB, further complicate the narrative. The exclusive female composition of year 1 students at RCSI-MUB could have introduced a potential bias, potentially skewing the results. However, gender distribution was more consistent in some years, particularly at UoS. The ANCOVA results revealed a p -value of 0.023, which falls below the conventional alpha level of 0.05, and p -value of 0.022 for EC subscale. This finding indicates that gender influences empathy levels among medical students. Female students exhibited higher empathy scores than their male counterparts, suggesting that gender differences might be an important factor to be considered in medical education and training. This insight into the gender disparities in empathic tendencies can be pivotal for medical educators and curriculum designers, as it highlights the need for tailored approaches to develop and nurture empathy among future healthcare professionals. However, we acknowledge the limitations in our demographic analysis due to the unavailability of additional sociodemographic details such as age, nationality, and socioeconomic status.

Most published studies have reported that female medical students are more empathic than their male counterparts [ 32 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. However, despite the overwhelming evidence supporting this correlation, there have been inconsistencies in the findings of some studies. Electroencephalography measures have not found significant gender differences in empathic abilities [ 44 ]. A cross-sectional study in Pakistan yielded results that align with the general trend, showing that females had significantly higher scores on specific items of the IRI and EC scales [ 45 ]. Nevertheless, when considering total empathy scores, both male and female students demonstrated similar levels of empathy overall. This emphasizes the importance of diverse participation in research to ensure comprehensive insights. Developing PT skills and strategies to mitigate PD are fundamental core competencies of medical graduates. Empirical research has argued that medical students’ distress may potentially lead to cynicism and subsequently affect their care of patients and their relationship with peers and faculty [ 46 ]. The manifestations and causes of PD, alongside its potential adverse personal and professional outcomes, are detrimental to enhancing EC among medical students [ 47 ]. These adverse consequences can be arrested by targeting medical education and paying more attention to fortifying the EC of medical students.

In our exploration of empathic development among medical students, the year-based analysis did not show significant differences across academic years, indicating consistency in empathy levels as students’ progress through their medical education. This finding adds an intriguing dimension to our understanding of empathy, suggesting that despite varying challenges and experiences encountered in different stages of medical education, the overall capacity for empathy among students remains relatively stable. However, this finding may be due to the cross-sectional nature of the study.

Despite significant similarities in the core curricula at RCSI-MUB and UoS, we posit that other factors unique to each institution, such as cultural contexts, teaching methodologies, student demographics, and extracurricular activities, might influence the development of empathic behaviors. Our study, therefore, recommends that researchers extend beyond the curriculum to include these broader institutional factors, offering a more nuanced perspective on how empathy is shaped within medical education settings.

Despite the significant role of empathy in enhancing healthcare outcomes, this important trait in medical students and residents has paradoxically been reported to decline during their clinical training [ 13 , 48 ]. Several factors can contribute, such as emotional exhaustion, suboptimal social support, burnout due to workload, and an inadequate curriculum [ 49 ]. For the professional enhancement of empathic skills of medical students, educators can consider well-structured faculty development programs [ 50 ], interprofessional education [ 51 ], simulation-based scenarios [ 52 ], and patient-centered medical education for effective communication [ 27 ]. Particular attention must be paid to interprofessional education, which carries great potential to enhance the empathic concerns of medical students [ 53 ].

Medical institutions might contemplate implementing structured empathy training modules, ensuring that future doctors are equipped with this indispensable soft skill. The observed differences between institutions underscore the need for a tailored approach, considering the unique characteristics of each institution. As the medical community continues to recognize the importance of empathy in patient care, research like ours calls for the need for continuous evaluation and refinement of medical curricula to foster this critical trait.

Strengths and limitations

This study was conducted on medical students of two premier medical institutions of the Middle Eastern region. This unique opportunity allowed us to analyze the cross-cultural and curricular influence of empathic approaches of medical students across the entire continuum of medical education. Additionally, this research yields significant findings that medical educators can use to modify the medical curriculum.

Our study has several limitations. First, based on the nature of the study, the number of participants may be considered small, limiting the generalizability of the findings. Second, this study identified differences in empathic approaches at defined time points rather than in a prospective manner. Due to the cross-sectional design, the research measured different participants at distinct stages rather than following the same individuals over time. Consequently, the findings reflect differences in empathy scores between separate groups rather than changes within the same individuals. This design limitation means that the study captures variations in empathy approaches at specific time points rather than longitudinally tracking how individual empathy develops or changes throughout progression in a medical program. Third, the results may not be used to cover other cultures or contexts. Finally, the self-reported insights of students to IRI may reflect subject bias. Individuals are likely to overestimate their empathy due to factors like social desirability.

Future directions

Our study used a self-administered IRI questionnaire and did not explore the empathy that takes place between patients and medical students. Future investigators should employ studies that could focus on patient perceptions of empathic student and physician behavior. Furthermore, expanding the sample size and incorporating longitudinal examination of participants to observe changes over time will certainly advance the understanding of medical students’ empathy. In addition, future research could benefit from incorporating gender balance and sociodemographic variables to present a more comprehensive demographic profile and to understand their potential influences on empathy development among medical students.

In summary, our study substantially contributes to the evolving nature of empathy development among medical students and the potential impact of curriculum and gender on this critical attribute. Though there are certain variations in insights about empathy, this study observed a unique fluctuating trend between RCSI-MUB and UoS across years and gender. Such disparities highlight the potential ramifications of curricular elements, teaching methodologies, clinical experiences, or even institutional ethos on students’ empathy development. This research urges medical educators to modify existing medical curricula by inculcating empathy into standard teaching and learning pedagogies.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Interpersonal Reactivity Index

Royal College of Surgeons in Ireland – Medical University of Bahrain

University of Sharjah

Bachelor of Medicine and Bachelor of Surgery

Empathic concern

Perspective taking

Personal distress

Analysis of Variance

Analysis of Covariance

Participant Information Leaflet

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Acknowledgements

All authors are thankful to the participants of the study.

This study received no external funding.

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School of Medicine, Royal College of Surgeons in Ireland Bahrain, Busaiteen, 15503, Bahrain

Haniya Habib, Sara Anjum Niinuma, Khadeja Alrefaie, Zarish Hussain, Prianna Menezes, Bincy Mathew & Alfred Nicholson

College of Medicine, University of Sharjah, Sharjah, 27272, United Arab Emirates

Heba Awad Al Khalaf, Mohammad Jasem Hani, Zeinab Yaareb Mosleh Al-Rawi & Salman Yousuf Guraya

University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, UK

Sornali Rani Roy

College of Medicine, Mohammed Bin Rashid University of Medical and Health Sciences, Dubai, 505055, United Arab Emirates

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SSG conceptualized the idea. HH, SAN, and SSG developed the protocol. HH, SAN, HAK, MJH, and ZYMA obtained ethical approval at the respective institutions. Data collection was performed by HH, SAN, KA, HAK, MJH, ZYMA, ZH, PM, SRR, and BM. Data analysis was conducted by KA, HAK, MJH, HH, SAN and SYG. Initial draft prepared by SYG, SSG, KA, HH, and SAN. Later on, BM, AN, and SSG improved the intellectual content of the initial draft. All authors contributed and proofread the final draft. SYG, SSG, and AN supervised the whole project and ensured the accuracy of the devised protocol and research integrity. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Salman Yousuf Guraya .

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The study was approved by the relevant Institutional Research Ethical Committees of RCSI-MUB (REC/2023/147/18-Jan-2023) and UoS (REC-23-03-12-01-F).

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Habib, H., Niinuma, S.A., Alrefaie, K. et al. Unfolding the empathic insights and tendencies among medical students of two gulf institutions using interpersonal reactivity index. BMC Med Educ 24 , 976 (2024). https://doi.org/10.1186/s12909-024-05921-1

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v.19(3Suppl 2); 2016

Transgender social inclusion and equality: a pivotal path to development

Vivek divan.

1 United Nations Development Programme Consultant, Delhi, India

Clifton Cortez

2 United Nations Development Programme, HIV, Health, and Development Group, New York, NY, USA

Marina Smelyanskaya

3 United Nations Development Programme Consultant, New York, NY, USA

JoAnne Keatley

4 University of California, San Francisco, Center of Excellence for Transgender Health, San Francisco, CA, USA

Introduction

The rights of trans people are protected by a range of international and regional mechanisms. Yet, punitive national laws, policies and practices targeting transgender people, including complex procedures for changing identification documents, strip transgender people of their rights and limit access to justice. This results in gross violations of human rights on the part of state perpetrators and society at large. Transgender people's experience globally is that of extreme social exclusion that translates into increased vulnerability to HIV, other diseases, including mental health conditions, limited access to education and employment, and loss of opportunities for economic and social advancement. In addition, hatred and aggression towards a group of individuals who do not conform to social norms around gender manifest in frequent episodes of extreme violence towards transgender people. This violence often goes unpunished.

The United Nations Development Programme (UNDP) views its work in the area of HIV through the lens of human rights and advances a range of development solutions such as poverty reduction, improved governance, active citizenship, and access to justice. This work directly relates to advancing the rights of transgender people. This manuscript lays out the various aspects of health, human rights, and development that frame transgender people's issues and outlines best practice solutions from transgender communities and governments around the globe on how to address these complex concerns. The examples provided in the manuscript can help guide UN agencies, governments, and transgender activists in achieving better standards of health, access to justice, and social inclusion for transgender communities everywhere.

Conclusions

The manuscript provides a call to action for countries to urgently address the violations of human rights of transgender people in order to honour international obligations, stem HIV epidemics, promote gender equality, strengthen social and economic development, and put a stop to untrammelled violence.

Those who have traditionally been marginalized by society and who face extreme vulnerability to HIV find that it is their marginalization – social, legal, and economic – which needs to be addressed as the highest priority if a response to HIV is to be meaningful and effective. Trans people's experiences suggest that although HIV is a serious concern for those who acquire it, the suffering it causes is compounded by the routine indignity, inequity, discrimination, and violence that they encounter. Trans people, and particularly trans women, have articulated this often in the context of HIV [ 1 ].

For a reader who is not trans, imagine a world in which the core of your being goes unrecognized – within the family, if and when you step into school, when you seek employment, or when you need social services such as health and housing. You have no way to easily access any of the institutions and services that others take for granted because of this denial of your existence, worsened by the absence of identity documents required to participate in society. Additionally, because of your outward appearance, you may be subject to discrimination, violence, or the fear of it. In such circumstances, how could you possibly partake in social and economic development? How could your dignity and wellbeing – physical, mental, and emotional – be ensured? And how could you access crucial and appropriate information and services for HIV and other health needs?

Trans people experience these realities every day of their lives. Yet, like all other human beings, trans people have fundamental rights – to life, liberty, equality, health, privacy, speech, and expression [ 2 ], but constantly face denial of these fundamental rights because of the rejection of the trans person's right to their gender identity. In these circumstances, there can be no attainment of the goal of universal equitable development as set out in the 2030 Agenda for Sustainable Development [ 3 ], and no effort to stem the tide of the HIV epidemic among trans people can succeed if their identity and human rights are denied.

The human rights gap – stigma, discrimination, violence

The ways in which marginalization impacts a trans person's life are interconnected; stigma and transphobia drive isolation, poverty, violence, lack of social and economic support systems, and compromised health outcomes. Each circumstance relates to and often exacerbates the other [ 4 ].

Trans people who express their gender identity from an early age are often rejected by their families [ 5 ]. If not cast out from their homes, they are shunned within households resulting in lack of opportunities for education and with no attempts to ensure attention to their mental and physical health needs. Those who express their gender identities later in life often face rejection by mainstream society and social service institutions, as they go about undoing gender socialization [ 6 ]. Hostile environments that fail to understand trans people's needs threaten their safety and are ill-equipped to offer sensitive health and social services.

Such discriminatory and exclusionary environments fuel social vulnerability over a lifetime; trans people have few opportunities to pursue education, and greater odds of being unemployed, thereby experiencing inordinately high levels of homelessness [ 6 ] and poverty [ 7 ]. Trans students experience resentment, prejudice, and threatening environments in schools [ 8 ], which leads to significant drop-out rates, with few trans people advancing to higher education [ 9 ].

Workplace-related research on lesbian, gay, bisexual, and trans (LGBT) individuals reveals that trans workers are the most marginalized and are excluded from gainful employment, with discrimination occurring at all phases of the employment process, including recruitment, training opportunities, employee benefits, and access to job advancement [ 10 ]. This environment inculcates pessimism and internalized transphobia in trans people, discouraging them from applying for jobs [ 11 ]. These extreme limitations in employment can push trans people towards jobs that have limited potential for growth and development, such as beauticians, entertainers or sex workers [ 12 ]. Unemployment and low-paying or high risk and unstable jobs feed into the cycle of poverty and homelessness. When homeless trans people seek shelter, they are housed as per their sex at birth and not their experienced gender, and are subject to abuse and humiliation by staff and residents [ 13 ]. In these environments, many trans people choose not to take shelter [ 14 ].

Legal systems often entrench this marginalization, feed inequality, and perpetuate violence against trans people. All people are entitled to their basic human rights, and nations are obligated to provide for these under international law, including guarantees of non-discrimination and the right to health [ 2 ]; however, trans people are rarely assured of such protection under these State obligations.

Instead, trans people often live in criminalized contexts – under legislation that punishes so-called unnatural sex, sodomy, buggery, homosexual propaganda, and cross-dressing [ 12 ] – making them subject to extortion, abuse, and violence. Laws that criminalize sex work lead to violence and blackmail from the police, impacting trans women involved in this occupation [ 15 ]. Being criminalized, trans people are discouraged from complaining to the police, or seeking justice when facing violence and abuse, and perpetrators are rarely punished. When picked up for any of the aforementioned alleged crimes or under vague “public nuisance” or “vagrancy” laws, their abuse can continue at the hands of the police [ 16 ] or inmates in criminal justice systems that fail to appropriately respond to trans identities.

The transphobia that surrounds trans people's lives fuels violence against them. Documentation over the last decade reveals the disproportionate extent to which trans people are murdered, and the extreme forms of torture and inhuman treatment they are subject to [ 16 – 18 ]. When such atrocities are perpetrated against trans people, governments turn a blind eye. Trans sex workers are particularly vulnerable to brutal police conduct including rape, sometimes being sexually exploited by those who are meant to be protectors of the law [ 15 ]. In these circumstances, options to file complaints are limited and, when legally available channels do exist, trans complainants are often ignored [ 19 ].

These experiences of severe stigma, marginalization, and violence by families, communities, and State actors lead to immense health risks for trans people, including heightened risk for HIV, mental health disparities, and substance abuse [ 20 , 21 ]. However, most health systems struggle to function outside the traditional female/male binary framework, thereby excluding trans people [ 22 ]. Health personnel are often untrained to provide appropriate services on HIV prevention, care, and treatment or information on sexual and reproductive health to trans people [ 20 , 23 ]. HIV voluntary counselling and testing facilities and antiretroviral therapy (ART) sites intimidate trans people due to prior negative experiences with medical staff [ 21 , 24 , 25 ]. Additionally, when trans women test HIV positive, they are wrongly reported as men who have sex with men [ 4 ]. Consequently, testing rates in trans communities are low [ 26 ], which serves to disguise the serious burden of HIV among trans people and perpetuates the lack of investment in developing trans-sensitive health systems. The economic hardships that trans people face due to their inability to participate in the workforce further complicate access to HIV, mental health, and gender-affirming health services. In short, hostile social and legal environments contribute to health gaps, and public health systems that are unresponsive to the needs of trans people.

In addition, understanding of trans people's concerns around stigma, discrimination, and violence, related as they are to gender identity, is often limited due to their being combined with lesbian, gay, and bisexual sexual orientation issues. However, trans people's human rights concerns, grounded in their gender identity, are inherently different and necessitate their own set of approaches.

Imperatives for trans social inclusion

In order to overcome the human rights barriers trans people confront, certain measures are imperative and should be self-evident, given the standards that States are obliged to provide under international law to all human beings. Paying attention to these is key to effectively addressing the systemic marginalization that trans people experience. Such action can have immeasurable benefits, including the full participation of trans people in human development processes as well as positive health and HIV outcomes. For trans people, the change must begin with the most fundamental element – acknowledgement of their gender identity.

The right to gender recognition

For trans people, their very recognition as human beings requires a guarantee of a composite of entitlements that others take for granted – core rights that recognize their legal personhood. As the Global Commission on HIV and the Law pointed out, “In many countries from Mexico to Malaysia, by law or by practice, transgender persons are denied acknowledgment as legal persons. A basic part of their identity – gender – is unrecognized” [ 19 ]. This recognition of their gender is core to having their inherent dignity respected and, among other rights, their right to health including protection from HIV. When denied, trans people face severe impediments in accessing appropriate health information and care.

Recognizing a trans person's gender requires respecting the right of that person to identify – irrespective of the sex assigned to them at birth – as male, female, or a gender that does not fit within the male–female binary, a “third” gender as it were, as has been expressed by many traditionally existing trans communities such as hijras in India [ 27 ]. This is an essential requirement for trans people to attain full personhood and citizenship. The guarantee of gender recognition in official government-issued documents – passports and other identification cards that are required to open bank accounts, apply to educational institutions, enter into housing or other contracts or for jobs, to vote, travel, or receive health services or state subsidies – provides access to a slew of activities that are otherwise denied while being taken for granted by cisgender people. 1 Such recognition results in fuller civic participation of and by trans people. It is a concrete step in ensuring their social integration, economic advancement, and a formal acceptance of their legal equality. It can immeasurably support their empowerment and act as an acknowledgement of their dignity and human worth, changing the way they are perceived by their families, by society in general, and by police, government actors, and healthcare personnel whom they encounter in daily life. UN treaty bodies have acknowledged this vital right of trans people to be recognized. The UN High Commissioner for Human Rights has recommended that States “facilitate legal recognition of the preferred gender of transgender persons and establish arrangements to permit relevant identity documents to be reissued reflecting preferred gender and name, without infringements of other human rights” [ 28 ].

Freedom from violence & discrimination

Systemic strategies to reduce the violence against trans people need to occur at multiple levels, including making perpetrators accountable, facilitating legal and policy reform that removes criminality, and general advocacy to sensitize the ill-informed about trans issues and concerns. Strengthening the capacity of trans collectives and organizations to claim their rights can also act as a counter to the impunity of violence. When trans people are provided legal aid and access to judicial processes, accountability can be enforced against perpetrators. Sensitizing the police to make them partners in this work can be crucial. When political will is absent to support such attempts in highly adverse settings, trans organizations and allies can consider using international human rights mechanisms, such as shadow reports made to UN human rights processes like the Universal Periodic Review, to bring focus to issues of anti-trans violence and other human rights violations against trans people.

Providing equal access to housing, education, public facilities and employment opportunities, and developing and implementing anti-discrimination laws and policies that protect trans people in these contexts, including guaranteeing their safety and security, are essential to ensure that trans individuals are treated as equal human beings.

The right to health

For trans people, their right to health can only be assured if services are provided in a non-stigmatizing, non-discriminatory, and informed environment. This requires working to educate the healthcare sector about gender identity and expression, and zero tolerance for conduct that excludes trans people. Derogatory comments, breaches of confidentiality from providers, and denial of services on the basis of gender identity or HIV status are some of the manifestations of prejudice. The right to non-discrimination that is guaranteed to all human beings under international law must be enforced against actions that violate this principle in the healthcare system. Yet, a multi-pronged approach that supports this affirmation of trans equality together with a sensitized workforce that is capable of delivering gender-affirming surgical and HIV health services is necessary.

Building on the commitments made by the UN General Assembly in response to the HIV epidemic [ 29 ], the World Health Organization (WHO) developed good practice recommendations in relation to stigma and discrimination faced by key populations, including trans people [ 30 ]. These recommendations urge countries to introduce rights-based laws and policies and advise that, “Monitoring and oversight are important to ensure that standards are implemented and maintained.” Additionally, mechanisms should be made available “to anonymously report occurrences of stigma and/or discrimination when [trans people] try to obtain health services” [ 30 ].

Fostering stigma-free environments has been successfully demonstrated – where partnerships between trans individuals and community health nurses have improved HIV-related health outcomes [ 31 ], or where clinical sites welcome trans people and conduct thorough and appropriate physical exams, manage hormones with particular attention to ART, and engage trans individuals in HIV education [ 32 ].

Advancing trans human rights and health

For all the challenges faced by trans people in the context of their human rights and health, promising interventions and policy progress have shown that positive change is possible, although this must be implemented at scale to have significant impact. Change has occurred due to the efforts of trans advocates and human rights champions, often in critical alliances with civil society supporters as well as sensitized judiciaries, legislatures, bureaucrats, and health sector functionaries.

Key strides have been made in the context of gender recognition in some parts of the world. In the legislatures, this trend began in 2012 with Argentina passing the Gender Identity and Health Comprehensive Care for Transgender People Act , which provided gender recognition to trans people without psychiatric, medical, or judicial evaluation, and the right to access free and voluntary transitional healthcare [ 33 , 34 ]. In 2015, Malta passed the Gender Identity, Gender Expression and Sex Characteristics Act , which provides a self-determined, speedy, and accessible gender recognition process. The law protects against discrimination in the government and private sectors. It also de-pathologizes gender identity by stating that people “shall not be required to provide proof of a surgical procedure for total or partial genital reassignment, hormonal therapies or any other psychiatric, psychological or medical treatment.” It presumes the capacity of minors to exercise choice in opting for gender reassignment, while recognizing parental participation and the minor's best interests. It stipulates the establishment of a working group on trans healthcare to research international best practices [ 35 ]. Pursuant to its passing the Maltese Ministry of Education working with activists also developed policy guidelines to accommodate trans, gender variant, and intersex children in the educational system [ 36 ]. Other countries, such as the Republic of Ireland and Poland, have also passed gender identity and gender expression laws, albeit of varying substance but intended to recognize the right of trans people to personhood [ 37 , 38 ]. Denmark passed legislation that eliminated the coercive requirement for sterilization or surgery as a prerequisite to change legal gender identity [ 39 ].

Trans activists and allies have also used the judicial process to claim the right to gender recognition. In South Asia, claims to recognition of a gender beyond the male–female binary have been upheld – in 2007, the Supreme Court of Nepal directed the government to recognize a third gender in citizenship documents in order to vest rights that accrue from citizenship to metis [ 40 ]; in Pakistan, the Supreme Court directed the government to provide a third gender option in national identity cards for trans people to be able to vote [ 41 ]; in 2014, the Indian Supreme Court passed a judgement directing the government to officially recognize trans people as a third gender and to formulate special programmes to support their needs [ 42 ]. These developments in law, while hopeful, are too recent to yet discern any resultant trends in improvements in trans peoples’ lives, more broadly.

More localized innovative efforts have also been made by trans organizations to counter violence, stigma, and discrimination. For instance in South Africa, Gender DynamiX, a non-governmental organization worked with the police to change the South African Police Services’ standard operating procedures in 2013. The procedures are intended to ensure the safety, dignity, and respect of trans people who are in conflict with the law, and prescribe several trans-friendly safeguards – the search of trans people as per the sex on their identity documents, irrespective of genital surgery, and detention of trans people in separate facilities with the ability to report abuse, including removal of wigs and other gender-affirming prosthetics. Provision is made for implementation of the procedures through sensitization workshops with the police [ 43 ]. In Australia, the Transgender Anti-Violence Project was started as a collaboration between the Gender Centre in Sydney and the New South Wales Police Force, the City of Sydney and Inner City Legal Centre in 2011. It provides education, referrals, and advocacy in relation to violence based on gender identity, and support for trans people when reporting violence, assistance in organizing legal aid and appearances in court [ 44 ].

Measures have also been taken to tackle discrimination faced by trans people, in recognition of their human rights – in 2015, Japan's Ministry of Education ordered schools to accept trans students according to their preferred gender identity [ 45 ]; in 2014 in Quezon City, the Philippines the municipal council passed the “Gender Fair City” ordinance to ensure non-discrimination of LGBT people in education, the workplace, media depictions, and political life. This law prohibits bullying and requires gender-neutral bathrooms in public spaces and at work [ 46 ]; in Ecuador, Alfil Association worked on making healthcare accessible to trans people, including training and sensitization meetings for health workers and setting up a provincial health clinic for trans people in collaboration with the Ministry of Health, staffed by government physicians who had undergone the training; and Transbantu Zambia set up a small community house providing temporary shelter for trans people, assisting them in difficult times or while undergoing hormone therapy. Similar housing support has been provided by community organizations with limited resources in Jamaica and Indonesia. 2

Towards sustainable development: time for change

Although there are other examples of human rights progress for trans people, much of this change is isolated, non-systemic, and insufficient. Trans people continue to live in extremely hostile contexts. What is required is change and progress at scale. The international community's recent commitment towards Sustainable Development Goals (SDGs) presents an opportunity to catalyze and expand positive interventions [ 3 ].

Preventing human rights violations and social exclusion is key to sustainable and equitable development. This is true for trans people as much as other human beings, just as the achievement of all 17 SDGs is of paramount importance to all people, including trans people. Of these SDGs, the underpinning support for trans people's health and human rights is contained in SDG 3 –“Ensure healthy lives and promote well-being for all at all ages,” SDG 10 – “Reduce inequality within and among countries,” and SDG 16 – “Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels.”

The SDGs are guided by the UN Charter and grounded in the Universal Declaration of Human Rights. They envisage processes that are “people-centered, gender-sensitive, respect human rights and have a particular focus on the poorest, most vulnerable and those furthest behind” and a “just, equitable, tolerant, open and socially inclusive world in which the needs of the most vulnerable are met” [ 3 ]. They reiterate universal respect for human rights and dignity, justice and non-discrimination, and a world of equal opportunity permitting the full realization of human potential for all irrespective of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, disability, or other status . The relationship between the SDGs and trans people's concerns has been robustly articulated in the context of inclusive development [ 47 ].

UN Member States have unequivocally agreed to this new common agenda for the immediate future. The SDGs demand an unambiguous, farsighted, and inclusive demonstration of political will. Their language clearly reflects the most urgent needs of trans people, for whom freedom from violence and discrimination, the right to health and legal gender recognition are inextricably linked.

Specifically in regard to trans people, the SDGs are a call to immediate action on several fronts: governments need to engage with trans people to understand their concerns, unequivocally support the right of trans people to legal gender recognition, support the documentation of human rights violations against them, provide efficient and accountable processes whereby violations can be safely reported and action taken, guarantee the prevention of such violations, and ensure that the whole gamut of robust health and HIV services are made available to trans people. Only then can trans people begin to imagine a world that respects their core personhood, and a world in which dignity, equality, and wellbeing become realities in their lives.

Acknowledgements and funding

The authors are grateful for the work of courageous trans activists around the world who have overcome tremendous challenges and continue to battle disparities as they bring about positive change. Many encouraging examples cited in this manuscript would be impossible without their contribution. The authors also thank Jack Byrne, an expert on trans health and human rights, whose work on the UNDP Discussion Paper on Transgender Health and Human Rights (2013) served as an inspiration for this piece, and JoAnne Keatley's effort to provide writing, editorial comment, and oversight. UNDP staff and consultants, who contributed time to this manuscript, were supported by UNDP.

1 Cisgender people identify and present in a way that is congruent with their birth-assigned sex. Cisgender males are birth-assigned males who identify and present themselves as male.

2 These illustrations are based on information gathered in the process of developing a tool to operationalize the Consolidated Guidelines on HIV prevention, diagnosis, treatment and care for key populations (WHO, 2014), through interviews with and questionnaires sent to trans activists. See also reference 31.

Competing interests

The authors have declared that no competing interests exist.

Authors' contributions

The concept for this manuscript was a result of collaborative work between all four authors. VD provided key ideas for content and led the writing for the manuscript. CC provided thought leadership and contributed writing, particularly on the SDGs, while MS provided writing and editorial input, as well as other support. JK advised on content and provided writing and editorial input and guidance. All authors have read and approved the final version.

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