In 1981, Pauly published results from a large retrospective study of people who had undergone
sex reassignment surgery. Participants in that study had much better outcomes: Among 83 FtM
patients, 80.7% had a satisfactory outcome (i.e., patient self report of “improved social and emotional
adjustment”), 6.0% unsatisfactory. Among 283 MtF patients, 71.4% had a satisfactory outcome, 8.1%
unsatisfactory. This study included patients who were treated before the publication and use of the
Standards of Care
.
Since the
Standards of Care
have been in place, there has been a steady increase in patient satisfaction
and decrease in dissatisfaction with the outcome of sex reassignment surgery. Studies conducted after
1996 focused on patients who were treated according to the
Standards of Care
. The fi ndings of Rehman
and colleagues (1999) and Krege and colleagues (2001) are typical of this body of work; none of the
patients in these studies regretted having had surgery, and most reported being satisfi ed with the
cosmetic and functional results of the surgery. Even patients who develop severe surgical complications
seldom regret having undergone surgery. Quality of surgical results is one of the best predictors of the
overall outcome of sex reassignment (Lawrence, 2003). The vast majority of follow-up studies have
shown an undeniable benefi cial effect of sex reassignment surgery on postoperative outcomes such
as subjective well being, cosmesis, and sexual function (De Cuypere et al., 2005; Garaffa, Christopher,
& Ralph, 2010; Klein & Gorzalka, 2009), although the specifi c magnitude of benefi t is uncertain from
the currently available evidence. One study (Emory, Cole, Avery, Meyer, & Meyer, 2003) even showed
improvement in patient income.
One troubling report (Newfi eld et al., 2006) documented lower scores on quality of life (measured
with the SF-36) for FtM patients than for the general population. A weakness of that study is that it
recruited its 384 participants by a general email rather than a systematic approach, and the degree
and type of treatment were not recorded. Study participants who were taking testosterone had typically
being doing so for less than 5 years. Reported quality of life was higher for patients who had undergone
breast/chest surgery than for those who had not (p<.001). (A similar analysis was not done for genital
surgery.) In other work, Kuhn and colleagues (2009) used the King’s Health Questionnaire to assess
the quality of life of 55 transsexual patients at 15 years after surgery. Scores were compared to those of
20 healthy female control patients who had undergone abdominal/pelvic surgery in the past. Quality
of life scores for transsexual patients were the same or better than those of control patients for some
subscales (emotions, sleep, incontinence, symptom severity, and role limitation), but worse in other
domains (general health, physical limitation, and personal limitation).
Two long-term observational studies, both retrospective, compared the mortality and psychiatric
morbidity of transsexual adults to those of general population samples (Asscheman et al., 2011; Dhejne
et al., 2011). An analysis of data from the Swedish National Board of Health and Welfare information
registry found that individuals who had received sex reassignment surgery (191 MtF and 133 FtM) had
signifi cantly higher rates of mortality, suicide, suicidal behavior, and psychiatric morbidity than those
for a nontranssexual control group matched on age, immigrant status, prior psychiatric morbidity, and
birth sex (Dhejne et al., 2011). Similarly, a study in the Netherlands reported a higher total mortality rate,
including incidence of suicide, in both pre- and post-surgery transsexual patients (966 MtF and 365
MtF) than in the general population of that country (Asscheman et al., 2011). Neither of these studies
questioned the effi cacy of sex reassignment; indeed, both lacked an adequate comparison group of
transsexuals who either did not receive treatment or who received treatment other than genital surgery.
Moreover, transsexual people in these studies were treated as far back as the 1970s. However, these
fi ndings do emphasize the need to have good long-term psychological and psychiatric care available
for this population. More studies are needed that focus on the outcomes of current assessment and
treatment approaches for gender dysphoria.
It is diffi cult to determine the effectiveness of hormones alone in the relief of gender dysphoria. Most
studies evaluating the effectiveness of masculinizing/feminizing hormone therapy on gender dysphoria
have been conducted with patients who have also undergone sex reassignment surgery. Favorable
effects of therapies that included both hormones and surgery were reported in a comprehensive review
of over 3000 patients in 79 studies (mostly observational) conducted between 1961 and 1991 (Eldh,
Berg, & Gustafsson, 1997; Gijs & Brewaeys, 2007; Murad et al., 2010; Pfäffl in & Junge, 1998). Patients
operated on after 1986 did better than those before 1986; this refl ects signifi cant improvement in
surgical complications (Eldh et al., 1997). Most patients have reported improved psychosocial
outcomes, ranging between 87% for MtF patients and 97% for FtM patients (Green & Fleming, 1990).
Similar improvements were found in a Swedish study in which “almost all patients were satisfi ed with
sex reassignment at 5 years, and 86% were assessed by clinicians at follow-up as stable or improved in
global functioning” (Johansson, Sundbom, Höjerback, & Bodlund, 2010). Weaknesses of these earlier
studies are their retrospective design and use of different criteria to evaluate outcomes.
A prospective study conducted in the Netherlands evaluated 325 consecutive adult and adolescent
subjects seeking sex reassignment (Smith, Van Goozen, Kuiper, & Cohen-Kettenis, 2005). Patients who
underwent sex reassignment therapy (both hormonal and surgical intervention) showed improvements
in their mean gender dysphoria scores, measured by the Utrecht Gender Dysphoria Scale. Scores for
body dissatisfaction and psychological function also improved in most categories. Fewer than 2%
of patients expressed regret after therapy. This is the largest prospective study to affi rm the results
from retrospective studies that a combination of hormone therapy and surgery improves gender
dysphoria and other areas of psychosocial functioning. There is a need for further research on the
effects of hormone therapy without surgery, and without the goal of maximum physical feminization
or masculinization.
Overall, studies have been reporting a steady improvement in outcomes as the fi eld becomes more
advanced. Outcome research has mainly focused on the outcome of sex reassignment surgery. In
current practice there is a range of identity, role, and physical adaptations that could use additional
follow-up or outcome research (Institute of Medicine, 2011).