Evidence of health benefits of medical transition: Gender dysphoria, body image, sexual functioning, and quality of life

Zinnia JonesMedical transition for the treatment of gender dysphoria, including hormonal and surgical treatment, is linked to improvements in health in many areas of trans people’s lives. Transition is known to be effective in resolving gender dysphoria itself, and is associated with better body image and congruence, sexual functioning, quality of life, and overall mental health, along with reductions in self-harming behaviors and suicidality. For these reasons, major professional organizations in the fields of psychology, psychiatry, endocrinology, pediatrics, obstetrics, and gynecology recognize the efficacy of medical transition for appropriately diagnosed patients and support the availability of these procedures.

Despite clear and consistent evidence that transition is beneficial to the health of trans people, much public discussion and private consideration of transition remains focused on potential negative outcomes, such as fertility loss, unsatisfying results, the (largely overblown) specter of regret, and various concerns often based on outright myths. As a result, the full scope of the likely benefits of transition is frequently glossed over and not adequately taken into account. This well-established evidence should be highly relevant to the general public’s beliefs regarding the value and importance of gender transition, as well as personal decisions by trans people about the suitability of transition in their own lives. A comprehensive understanding of what transition can offer us requires more than concerns about the possible downsides – it must also incorporate an appreciation of the highly probable benefits.

 

Gender dysphoria

A meta-analysis of studies of medical transition (Murad et al., 2010) found that gender dysphoria, the experience of distress with one’s assigned sex and associated traits, was significantly reduced in a strong majority of trans people following transitioning:

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%). Proportion in MF subgroup is 71% (41–93%) and in FM subgroup is 86% (65– 98%).

When measured by the Utrecht Gender Dysphoria Scale (UGDS/UGS), FM and MF individuals had minimal gender dysphoria remaining after transition, which was comparable to gender concordant controls without GID and better than dysphoria in untreated individuals with GID. They reported good satisfaction with the new assigned sex, physical appearance, had no doubts about their new gender role or their ability about maintaining this role in the future. Satisfaction with primary and secondary sex characteristics was significantly higher when pre- and posttransition therapy data were compared.

Cohen-Kettenis & van Goozen (1997) observed that trans people who transition in adolescence using puberty blockers may have a more complete resolution of their gender-dysphoric symptoms than those who transition in adulthood:

We expected that the outcome of this young group would be relatively favorable compared with the outcome among older groups. In the first follow-up study among adult Dutch transsexuals (N = 141) who had undergone SRS (Cohen-Kettenis and Kuiper, 1988; Kuiper and Cohen-Kettenis, 1988), SRS was found to solve gender problems but had not necessarily alleviated other problems. Similar results have been found in non-Dutch samples (for a review of 79 follow-up studies, see Pfafflin and Junge, 1992). The less positive results among adults may, in our view, be due to the fact that they have had to live under adverse circumstances for a longer period than individuals who are treated in adolescence. …

The difference between pre- and posttest score in gender dysphoria was highly significant ( p < .001) (Table 1). The mean posttest scores of the MF transsexuals were completely in the range of the mean score of the aforementioned 87 female controls (mean = 15.7; SD = 5.4); likewise, the mean posttest score of the FMs did not differ significantly from the mean score of the aforementioned 58 male controls (mean = 14.2; SD = 2.9). In addition, the MF group reported feeling highly feminine and hardly masculine at all in response to qu estions on masculinity and femininity, while almost exactly the reverse pattern was found in the FM group (Fig. 1).

These results were replicated in a followup study of trans youth (de Vries et al., 2014):

After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. …

Results of this first long-term evaluation of puberty suppression among transgender adolescents after CSH treatment and GRS indicate that not only was GD resolved, but well-being was in many respects comparable to peers.

 

Body image and bodily congruence

Medical transition has been found to be associated with a decrease in uneasiness with one’s body as well as greater satisfaction with various bodily features and an improved body image overall. Bandini et al. (2013) studied body uneasiness in trans people who had undergone genital reassignment surgery, as well as those who had not, finding a consistent reduction in body dissatisfaction following surgery:

GID subjects wGRS showed lower body dissatisfaction compared with those w/oGRS. …

Considering the differences between GID subjects with and without GRS, we found that in the first group, body uneasiness was dramatically reduced, as most of them reached control values. This result is in line with different findings suggesting the positive effect of GRS on body dissatisfaction in GID subjects, due to a reduction in the discrepancy between biological and desired sex [33–35]. Moreover, no difference in body uneasiness was observed between MtFs and FtMs, as previously reported [17]. As far as BUT subscales scores are concerned, the higher value of body image concerns in GID w/oGRS subjects supports the positive effects of reassignment on such preoccupations.

Fisher et al. (2014) additionally found that hormone therapy is associated with a reduction in body dissatisfaction among trans women, and Isung et al. (2017) observed that trans women who had undergone facial feminization surgery showed a significant improvement in their body image and sense of bodily congruence with their gender.

Existing studies indicate that this trend holds true for trans youth as well as adults. Cohen-Kettenis & van Goozen (1997) noted high rates of satisfaction with appearance and sexual characteristics among trans people who transitioned in adolescence:

With respect to their general appearance, the majority of the group reported satisfaction: 100% of the MFs and 60 % of the FMs were satisfied, while 40% of the FMs were neutral. This is in line with the int erviewer’s observation that it was difficult to discern any signs of the biological sex. Satisfaction with primary and secondary sexual characteristics after treatment increased significantly.

de Vries et al. (2014) also observed improvement in body satisfaction among trans youth following hormone therapy and reassignment surgery:

Figure 1 and Table 2 show that GD and body image difficulties persisted through puberty suppression (at T0 and T1) and remitted after the administration of CSH and GRS (at T2) (significant linear effects in 3 of 4 indicators, and significant quadratic effects in all indicators). Time by sex interactions revealed that transwomen reported more satisfaction over time with primary sex characteristics than transmen and a continuous improvement in satisfaction with secondary and neutral sex characteristics. Transmen reported more dissatisfaction with secondary and neutral sex characteristics at T1 than T0, but improvement in both from T1 to T2. …

Satisfaction with appearance in the new gender was high, and at T2 no one reported being treated by others as someone of their assigned gender.

 

Sexual functioning

A number of studies have found that sexual functioning, health, and satisfaction among trans people are improved following transition. A meta-analysis by Murad et al. (2010) found a marked increase in sexual functioning after transitioning in both trans women and trans men:

Pooling across studies shows that after sex reassignment, 72% of individuals with GID reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). This proportion in MF subgroup is 63% (45–79%) and in FM subgroup is 80% (68–89%).

The researchers of included studies assessed sexual satisfaction, sexual health and sexual function by using semi-structured interviews, clinical encounters, or designed their own questionnaires to evaluate satisfaction with intercourse, sex life and orgasm. In most studies, more than half of MF or FM reported higher satisfaction of sexual function in terms of existence, frequency or quality. On the contrary, only in one study, Rauchfleisch et al. reported poor sexual satisfaction and outcomes.

De Cuypere et al. (2005) found that a majority of trans subjects reported being very satisfied with their sex life, most experienced improvement in their sex life following sex reassignment surgery, and sexual excitement was more frequent among trans women after surgery:

For those who had sexual activity, 30 (60%) participants were very satisfied with their sex life, 18% remained neutral, and 22% were dissatisfied (single-item measure; Table IV). The participants with a partner were more satisfied with their sex life than those who remained single, χ2(1, n = 55) = 3.61, p = .058. A significant correlation between general and sexual satisfaction was found, r(49) = .49, p < .001. When evaluating changes in sex life before and after SRS, 75.5% of participants indicated an improvement and 12.3% a worsening. Pain, lack of sensation, and difficulties to relax were reported in this context. A correlation between the improvement in sex life and the satisfaction with the new primary sex characteristics (scored with BIS) was found, r(47) = .29, p = .043. This correlation was not found when evaluating satisfaction with the secondary or neutral sexual characteristics. After SRS, the participants were more often sexually excited than before. This difference was only statistically significant in the male-to-females, χ2(1, n = 29) = 5.78, p = .016. The more frequently participants experienced sexual excitement, the more they felt their sexual life had improved, r(49) = .38, p = .007. …

In general, most transsexual individuals indicated an improvement in their sex life and more sexual excitement after SRS. Most participants were able to reach orgasm both through masturbation and intercourse. Before surgery, they experienced their body as strange and not belonging to themselves. Often they did not accept being touched by anybody (even by themselves). They were not preoccupied by sex, but were preoccupied by getting rid of the unwanted sex organs. After SRS, sexuality can only improve, on condition they have the right body, with the right genitals. Our data showed that an improvement of sex life and sexual satisfaction was correlated with the satisfaction with the surgical results and the new primary sex characteristics.

Wierckx et al. (2014) also observed that spontaneous sexual desire was more frequent among trans women who had vaginoplasty than among those who had not, and a majority of trans men reported an increase in sexual desire after transitioning as well:

Concerning the associations between cross-sex therapy and sexual desire, it was observed that trans women who had undergone vaginoplasty experienced higher levels of sexual desire compared with those who were scheduled to undergo this surgery. It is likely that the relief of gender dysphoria due to a body image more congruent with the gender identity has positive effects on sexual functioning or the other way around that the presence of male genitalia has negative effects on sexual functioning. As a result, trans women may experience more satisfying sexual relationships after genital surgery.

 

Quality of life

Measurements of quality of life are consistently improved among trans people following transition. Murad et al.’s (2010) meta-analysis reports that an overwhelming majority of trans women and trans men report a better quality of life after transitioning:

Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in quality of life (95% CI = 0Æ72–0Æ88; 16 studies; I 2 = 78%). This proportion in the MF subgroup is 84% (68–95%) and in the FM subgroup is 78% (67–87%).

In most of the included studies, at least two thirds of individuals with GID reported improvement in some aspects of their quality of life such as more stable relationships, better adjustment, satisfaction with sex reassignment, and overall happiness and contentness. In a study by Rehman et al., 27/28 MF individuals reported life becoming easier and more comfortable posttransition. In another study by Smith et al., quality of life measured by the Affect Balance Scale (only the negative components of the scale used) was better in treated MF and FM compared with those untreated; but the difference did not achieve statistical significance. The treated individuals in this study had better resolution of dysphoria and improved psychosocial and psychological functioning. Van Kemenade et al. found that treatment with an antiandrogen for 8 weeks increased feelings of relaxation and energy in MF transsexuals.

Financial, professional status and employment situation were satisfactory postsex reassignment and when compared with before transition, they were perceived as improved.

Gorin-Lazard et al. (2012) further confirmed these findings, observing that the administration of hormone therapy is associated with an improved quality of life among trans people:

Hormonal therapy was significantly associated with higher scores on the social, emotional, and mental QoL dimensions (SF, RE, MH, and MCS). …

Figures 2 and 3 illustrate the QoL differences between the 17 nonhormonal transsexuals, the 44 hormonal transsexuals, and the age- and sex-matched controls. Hormonal transsexuals presented significantly higher scores on the MH (79.4 16.1 vs. 73.4 2.6, P = 0.02) and GH (79.4 16.1 vs. 69.5 2.3, P = 0.001) dimensions, whereas nonhormonal transsexuals reported lower scores than controls on the RE dimension (54.9 40.7 vs. 86.2 4.1, P = 0.01). …

Another important finding is the disparity between the nonhormonal and the hormonal transsexuals, as hormonal therapy is associated with higher scores of general and MH, whereas the absence of hormones is associated with lower scores of the RE subscale. These results underline the suffering of nonhormonal transsexuals and the probable favorable evolution of their QoL with hormonal therapy in a sex reassignment procedure. Our results suggest the positive psychological effects of hormonal therapy rarely identified in previous reports [2,4]. It seems to suggest that treatment with hormones allows individuals to feel as good or better than controls.

Gómez-Gil et al. (2014) also found an association between use of hormone therapy and greater quality of life among trans people, and Ainsworth & Spiegel (2010) observed that both facial feminization surgery and genital reassignment surgery are linked to a better mental health-related quality of life in trans women.

 

Gender transition effectively treats gender dysphoria and is associated with improved health outcomes in trans people

Substantial and consistent evidence shows that gender transition treatments, including cross-sex hormone therapy and gender-affirming surgeries, are effective in addressing the core symptoms of gender dysphoria. There is evidence that the resolution of gender dysphoria may be more thorough when treatment is initiated using puberty blockers in adolescence. Medical transition is additionally known to improve perception of body image and comfort with one’s body and its sexual characteristics, and most trans people find that transitioning improves their sexual functioning as well as their overall quality of life. Sufficient evidence exists to recommend medical transition as a beneficial treatment for those diagnosed with gender dysphoria.

Next: Benefits of medical transition in symptoms of depression, anxiety, distress, and dissociation.

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About Zinnia Jones

My work focuses on insights to be found across transgender healthcare, public health, psychiatry, and history of medicine, integrating these many perspectives and guided by the lived experiences of trans people. I live in Orlando with my family, and work mainly in technical writing.
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