Quality of Life in Treated Transsexuals

Rockwell_Girl_at_Mirror“And all I wanted was the simple things / A simple kind of life”

Introduction

In debates and discussions with those who are unfamiliar with or unfriendly to the transgender community, a frequent point which is brought up is “but hormones and surgery don’t help transgender people! I read an article somewhere that said that!” Typically the article cannot be cited or found, but in some cases it can, and using that one source someone makes a personal policy decision on an issue so complex and multifaceted that even most transgender people don’t really understand it.

Another fallacy is that the layperson often focuses on one single metric – suicide rates – as being the definition of “success” for transgender patients. Meaning that to them, a population which enjoys significantly better health and well-being as a whole from a course of treatment should not have that treatment if the mortality risk from any cause remains the same. That’s a dangerous fallacy which if applied to other medical treatments or drugs might very well prohibit their use.

My goal in this article is to perform a study on the studies which are out there in the public arena, to summarize their results, and to give my critical take on each of them to answer these final questions:

1)      Does hormone treatment result in a greater quality of life for transsexuals?

2)      Does sex reassignment surgery result in a greater quality of life for transsexuals?

3)      Do either of the above result in a reduction in the suicide rate of transsexuals?

Definitions

First I want to make some definitions to simplify reading this article.

MtF/FtM: Male to female transsexuals/Female to male transsexuals. Used as an abbreviation in tables.

QOL: Quality of life.

Sex Reassignment Surgery (SRS): Synonymous with “gender reassignment surgery,” “gender confirmation surgery,” etc.

Transgender: An umbrella term for an individual whose gender identity and/or gender expression differs from their physical sex. This person may, or may not be, actively transitioning their physical form, social status, and legal status to match their gender identity.

Transsexual: An individual whose gender identity differs from their physical sex, and who is actively transitioning their physical form, social status, and legal status to match their gender identity.

Transman/Transmen: Female to male transsexuals.

Transwoman/Transwomen: Male to female transsexuals.

Study Design

Google Scholar, PubMed, and other online databases were searched for studies using such terms as “transgender,” “transsexual(s),” “quality of life,” “suicide,” “hormone(s),” and other terms which were seen as likely to return results. Studies were limited from 2004-2015 in the search engine to reflect the fact that social acceptance, medical treatments and procedures, and opportunities for transsexuals have undergone significant improvements in the last decade. However, one study from 1998 was included due to it being very commonly cited online as definitive and conclusive proof that transsexuals suffer declines in their well-being from hormones and SRS. A total of more than 350 papers were initially screened via their abstracts, with only those dealing directly with the subject of quality of life and having a sufficient sample size being reviewed in-depth.

Transsexual Quality of Life Study Results

A summary of these studies in chronological order is shown in the following table.

Year Lead Author MtF FtM Status Before & After? Overall Improvement? Suicide Risk?
1998 Rauchfleisch 13 4 Post-SRS YES NO for MtF, SOME for FtM. Poorer QOL for most. N/A
2004 De Roche 9 4 Post-SRS YES YES, in 8/9 MtF and 4/4 FTM. N/A
2005 De Cuypere 32 23 Post-SRS YES YES, but most assessments focused on sexual performance and orgasm. N/A
2005 Smith 77 49 Mostly post-SRS YES YES, broadly improves, with unhappiness in specific areas. N/A
2006 De Cuypere 33 23 Post-SRS YES YES – social satisfaction and other psychosocial factors greatly improved. In most cases they were equal to the general population. LOWER – Much fewer suicide attempts, but still much more than the general population.
2006 Lawrence 232 0 Post-SRS YES None consistently regretted, 6% intermittently regretted SRS. Regret a function of surgical success not gender transition. Happiness related to year of surgery. N/A
2006 Lobato 18 1 Post-SRS YES YES – a small, limited study which showed overall sexual experience improved. Other improvements were noted but not significant. N/A, although this study is often misquoted as being negative on suicide risk.
2006 Newfield 0 376 Various NO YES, improvement with hormones and top surgery. N/A
2006 Zimmerman 24 16 Post-SRS NO YES – 35/40 were very satisfied or satisfied with their new bodies. All transmen and 22 of the 24 transwomen were very satisfied or satisfied with the resolution of their gender identity disorder. N/A
2009 Bazarra-Castro 58 37 Various YES YES, Mental happiness improved substantially, body satisfaction significantly. N/A
2009 Kuhn 52 3 Post-SRS NO NO, poorer QOL than controls. N/A
2009 Weyers 50 0 Post-SRS YES YES – post-SRS women had a physical and social quality of life similar to the general population. “Self-perceived general health status significantly improved within the year following SRS, and none of the transsexual women openly regretted SRS.” N/A
2010 Ainsworth 247 0 Various YES YES, surgery of any kind improved body and mental satisfaction equal to the general female population. N/A
2010 Murad (meta) 1,091 801 Post-SRS YES YES, QOL improved for 80% of subjects. LOWER
2010 Parola 15 15 Post-SRS YES YES, 28/30 satisfied. N/A
2011 Asscheman 966 365 Various NO Health and mortality were only compared to the general population, not to other transsexuals or even gender dysphoric individuals. Cancer risk was comparable to the general population, but higher for some specific cancers. Ischemic heart disease higher likely due to ethinyl estradiol use. Drug-related deaths were much higher than the general population. MIXED – no comparison was made to transsexual control groups.
2011 Dhejne 191 133 Post-SRS NO NO, health was reported to decline. HIGHER
2011 Wierckx 0 49 Post-SRS YES YES, generally very satisfied. N/A
2012 Gómez-Gil 113 74 Hormones, Post-SRS NO YES, QOL was much better for those on hormones, but SRS made little statistical difference. N/A
2012 Gorin-Lazard 31 30 Hormones YES YES, QOL was much better on hormones, but still less than the general population. N/A
2012 McNeil <889 <889 Various YES YES, significant improvements at all stages of transition. Hormones and surgery led to improvements in more than 80%. N/A
2012 Motmans 148 107 Mostly SRS NO SOME, small improvements compared to general population. N/A
2013 Colizzi1 78 29 Hormones, some SRS NO YES, significant improvements to mental health for those on hormones. Depression and anxiety greatly decreased. N/A
2013 Colizzi2 45 25 Hormones YES YES, hormones greatly reduced both physiological and perceived stress. N/A
2013 Gómez-Gil 119 74 Hormones, some SRS YES YES, physical, social, and psychological improvements. Overall QOL significantly improved. N/A
2013 Gooren 60 0 Hormones, some SRS NO NO, hormones did not significantly improve QOL. Ability to dress, present as female, and acceptance by family and friends were significant factors. N/A
2013 Gorin-Lazard 36 31 Hormones, some SRS NO YES, self-esteem, mood, and quality of life improved. Depression was greatly reduced. N/A
2014 Boza 160 83 Hormones to surgery. NO MAYBE – lower depression, but causality not proven. N/A
2014 Davis 0 208 No treatment to surgery. NO YES, clear evidence of improved mental health. N/A
2014 De Vries 22 33 Hormones to surgery. NO YES, QoL improved as treatment progressed from blockers to hormones to surgery. N/A
2014 Fisher 66 59 Hormones only. YES MIXED, transwomen saw significant improvements, transmen did not. N/A
2014 Garcia 0 25 Post-SRS NO YES, surgery satifaction level was high and no subject had surgical regrets. However, QOL was not generally asked. N/A
2014 Heylens 46 11 Hormones to surgery. YES YES, surgery satisfaction level was high and no subject had surgical regrets. However, QOL was not generally asked. NO
2014 Peluci 0 45 Hormones. YES YES, three different testosterone treatments all resulted in better QOL. NO
2015 Ruppin 35 36 Hormones to surgery. YES YES, although note was made on QoL being highly dependent upon social support. Primary regret was not starting the process earlier. NO

Summary

A total of 34 studies were reviewed, 33 within our established search parameters and 1 outside those parameters. Body satisfaction and mental improvements, improved social functioning, and a significant increase in quality of life resulting from hormones and/or SRS were clearly indicated in 26 of 34 studies. A decline in physical or mental health, or quality of life, was clearly indicated in 3 of 34 studies, and weak improvement or mixed or ambiguous results were indicated in 5 of 34 studies. It must be called out that the Murad study of 2010, while important due to its breadth, may contain duplicated results as it was a meta-study. Furthermore, one of the negative studies was from 1998, which was 6 years outside our original search parameters. If this study is omitted, then 79% of the studies surveyed showed positive changes from transition, 15% showed weak improvement or mixed or ambiguous results, and 6% showed negative changes from transition.

It’s important to note that the large majority of studies found since 2004 do not address suicide risk, and among those reviewed two indicated a lower risk, and one a higher risk.

Overall, scientific studies published since 2004 overwhelmingly indicate that hormones and SRS result in clear improvements in the quality of life of transsexual patients.

Detailed Results from the Studies Referenced Above

1998

This early paper was included due to its common reference by anti-transgender persons, and it is also referenced in the 2004 study by De Roche et al. In this study 48 transwomen and 21 transmen who consulted the Basel University Psychiatric Outpatient-Department from 1970 and 1990 were followed up on to determine their assimilation into society and quality of life. However, only 13 transwomen and 4 transmen could be included in the final analysis. The quality of life of the transwomen had “significantly deteriorated” – 9 on them were on welfare or disability and were isolated socially. Eight only experienced sexual pleasure, with difficulty, 10 suffered from “anxieties, depression or addictions.” Three regret SRS and two have tried reversal. In terms of the transmen, 2 out of 4 are professionally active and live in steady relationships. The other 2 suffer from depression and addiction. This study has significant problems in that it only examines the outcomes of 17 transsexuals who transitioned over a period from 1970 to 1990 – the dark ages of transgender life. (Rauchfleisch)

2004

This study was inspired by the 1998 study by Rauchfleisch et al. This paper noted that “Following negative feedback from operated transsexuals which included difficulty in coping with everyday life, being unable to work and ensuing social disintegration, and in one case the manifestation of schizophrenia, procedures were changed at the Basel University Clinic.” This is very critical, as many anti-transgender persons on the net hold up the 1998 German paper as the holy grail of transgender error. This paper still has some issues, however. They chose 9 out of 53 transwomen as potential surgical candidates, a very low number by today’s standards. However, it did find that 58 months post-surgery 8 out of 9 subjects “were socially well-integrated and satisfied with the results of the operation.” It was noted that the one who was worse off was now unemployed and on a disability pension. They also chose 4 out of 9 transmen to evaluate, and found that all of them who had surgery improved. (De Roche)

 2005

This study was a long-term follow-up of 32 transwomen and 23 transmen, an average of 4-6 years post-SRS. Many parameters of sexual satisfaction were studied from this population, and vital statistics and hormone assays done. For transwomen a 95.2% were happy with their breast augmentation, and only 4.8% neutral (none were dissatisfied). For transmen 78.5% were happy with their mastectomy, 21.4% were neutral, and none were dissatisfied. (Note that the values in this summary are from the original tables, and do not add exactly to 100% due to rounding error.) Transwomen who had vaginoplasty were 86.2% likely to be happy with the results, 10.3% were neutral, and 3.4% were unhappy. Transmen who had phalloplasties were 88.8% likely to be happy, and 11.1% were neutral (none were unhappy). Compared to their pre-surgical lives, transwomen felt 75.8% of the time that there was an improvement, and 13.8% of the time that there was a worsening. Transmen reported an improvement 75% of the time, and a worsening 10% of the time. Sexual arousal was much easier for all subjects compared to before surgery. (De Cuypere)

This study focused on the entire transition experience, from counseling to SRS, and looked at a total of 162 individuals (104 transwomen and 58 transmen). A total of 94 were termed “homosexuals” by the study, meaning that they were heterosexual after SRS. Follow-up data was taken from 126 adults (77 transwomen, 49 transmen, and 71 being “homosexual”). The results of the follow-up showed that gender dysphoria was “virtually absent” in the study group after SRS. Body satisfaction increased to 91.6%, with 8.4% being “neutral,” and no subjects reported as being dissatisfied. Satisfaction with their physical appearance improved, and their negativism, shyness, and other psychological scores improved. Most psychological results fell into the normal population values after SRS. Overall 98.4% expressed no regrets about their surgery (although satisfaction scores were 70.1% for transwomen with SRS and 28.9% for transmen with breast removal). Five expressed regrets during treatment, but had no desire to return to their prior gender role. Social dissatisfaction unrelated to surgery was still higher than the normal population. In terms of sex life, 88.5% of those with a steady partner expressed satisfaction. It was also noted that lack of cosmetic success was a predictor of poor sexual functioning due to lowered psychological stability and mood. (Smith)

2006

A long-term follow-up of 33 transwomen and 23 transmen was done by the same authors of a 2005 study on sexual function, and focused on psychosocial factors instead. For transwomen, gender dysphoria after SRS was not distinguishable from the cisgender female control group, representing a huge improvement. Similar but better results were seen for the transmen. GAF scores were assessed but only compared against other transsexuals. No significant differences were seen between the transsexual subjects and the general population on the Symptom Checklist assessment (which is good). The suicide attempt rate decreased significantly, from 29.3% to 5.1%. However, this was still much higher than the general population, which had a rate of 0.15%. Physical credibility in their new gender was good, save for voice in transwomen. Overall, transwomen were significantly less likely to “pass” than transmen. Satisfaction levels with social life substantially and broadly increased for most transwomen and transmen, with very few being dissatisfied after transition. Transwomen were satisfied with their SRS 88.6% of the time, transmen 85.2% of the time. (De Cuypere)

The results of a study of 232 transwomen who all underwent the same surgery with the same physician and using the same surgical techniques were evaluated. The women underwent surgery from 1994-2000, with one change in 1997 where electrolysis before surgery was recommended. Only 6% of the patients reported that they sometimes regretted surgery, and none reported consistent regret. Patients overwhelmingly reported that they were happier with their overall quality of life after surgery. Happiness with their life was associated with surgical results, with those suffering from complications having most of the unhappiness of the group. In terms of orgasmic performance, 36% could almost always achieve orgasm, 12% more than half the time, and 15% less than half the time. Only 33% could rarely or never achieve orgasm. One problem with this study was only 32% of eligible persons sent in their questionnaires, with the time from surgery playing an important role in the willingness to discuss surgical results. (Lawrence)

A Brazilian study of 18 transwomen and 1 transman in Brazil is sometimes deliberately mis-cited as evidence that surgery increases the chance of suicide attempts in transsexuals who have SRS (See Table 2 in the original article). However, what they fail to note is the history of psychosocial problems listed in that table represents a lifetime history – all it tells us is that gender dysphoria or other coincident problems drove them to suicide attempts at some point in their lives. This is a similar deliberate misquoting to what folks do with the large “Injustice at Every Turn” study from 2011, where the fact that 41% reported attempting suicide is a lifetime risk, and not a pre- or post-transition breakdown. In this study no patients regretted surgery, and sexual experience was said to have improved for 83.2% of the subjects. Partnerships were reported as being more common and easier to maintain, although with a sample this small statistical significance was not reached. About 1 in 4 reported improved family relationships, and none reported worsening family relationships. (Lobato)

A survey of 376 transmen on their quality of life found that their general health, social functioning, emotional, and mental health was diminished compared to the general male population. However, their decreased physical health was similar to that of women of their age. There was no direct correlation between the number of years in treatment and dissatisfaction. The population was highly educated when compared to the general population, with half having a Bachelor’s degree or greater education. However, the majority earned less than the national average. It was also noted that only 20% of the participants were transsexual and identified as male, although 248/376 had taken testosterone in the past, and 136/376 had had top surgery. In short, a significant number of the subjects in this study were untreated transgender persons. However, this data is telling – those who took testosterone had a physical health which was about the same as those who hadn’t, but their mental health was much better (p < 0.001). The results were a little more vague for those receiving top surgery – there was improvement in both physical and mental health, but in physical health the improvement was not significant, and was only slightly significant in terms of mental health. “Bottom surgery” SRS was not studied directly. (Newfield)

A German study of 24 transwomen and 16 transmen who had undergone SRS found very positive results. Of the group, 35/40 were very satisfied or satisfied with their new bodies, and 22 out of 40 were very satisfied or satisfied with their sexual ability post-SRS. All 16 of the transmen and 22 of the 24 transwomen were very satisfied or satisfied with the resolution of their gender identity disorder, with the remaining 2 transwomen reporting they were undecided. Suicide risk was not assessed. (Zimmerman)

2009

In a lengthy research dissertation from Spain (which admittedly contains some errors; for example, Christine Jorgensen was not the first to undergo transsexual surgery; see Lili Elbe, Roberta Cowell, etc.) a group of 58 transwomen and 37 transmen were studied at the Endocrine Outpatient Clinic at the Max Planck Institute for Psychiatry in Munich. Patients underwent psychotherapy, hormone therapy, and/or SRS. Twenty-five of the transmen and 41 of the transwomen had undergone SRS. The study was done by a simple mail survey. The average length of treatment with hormones was 6.5 years for transwomen and 4.9 years for transmen. A variety of positive and negative effects from hormone therapy were observed from the survey, with only a single case of cancer for a transman, 2 heart attacks (one for a transwoman and one for a transman), and one blood clot in a transwoman. Weight increased in more than 81% of the entire population. Transwomen were 76% satisfied with psychotherapy, 76% satisfied with their hormone therapy and 88% satisfied with their SRS. Transmen were 77% satisfied with psychotherapy, 88% satisfied with their hormone therapy and 78% satisfied with their SRS.

The improvement in the quality of life of the subjects was self-assessed on a qualitative scale at different stages in their transition, on a scale ranging from 0 to 100. For transwomen, pre-treatment their psychological score was 39, during psychotherapy this increased to 59, then to 68 under hormone therapy. Surgery increased this to 88. For transmen, pre-treatment their psychological score was 38, during psychotherapy this increased to 60, then to 81 under hormone therapy. Surgery increased this to 92. In terms of their physical well-being, the scores at the four stages of treatment for transwomen were 70, 74, 76, and 82 from pre-treatment to surgery. For transmen, these scores were 66, 71, 82, and 80 from pre-treatment to surgery, respectively. (Bazarra-Castro)

A study was conducted in Sweden of 52 transwomen and 3 transmen to determine their current quality of life. Note, however, this study did not focus on, nor even address, how their quality of life changed after SRS. From the study:

“General health was considered significantly lower, physical and personal limitations were significant greater in TS, and general life satisfaction was significantly lower in TS compared with controls. Role limitations were significantly lower in TS compared with controls, which could be a sign for good gender assimilation and well-being.”

What this tells us is that even after SRS these patients still faced significant life challenges – something hardly disputed by anyone. It was also noted that the control group as a whole had not experienced major surgery, and thus there could be bias due to their not having the general life and health impacts of having undergone such surgery. (Kuhn)

A Belgian study of 50 transwomen post-SRS was conducted to see how their quality of life may have changed. Where applicable, metrics of their physical and mental status were compared against 766 Dutch women and 1,412 American women in 8 different categories, and there was no significant difference noted (the transwomen were typically slightly lower in scores, but sometimes slightly higher in scores). Women in relationships had significantly better scores than those who didn’t (understandably). Regret over SRS was also assessed, with 96% expressing that they “never” regretted SRS, and 4% expressing “sometimes.” Overall, the study noted “self-perceived general health status was found to have significantly improved within the year following SRS, and none of the transsexual women openly regretted SRS.” (Wyers)

2010

A study which focused on facial feminization surgery (FFS) and SRS compared transwomen who had had one, the other, both, or neither to determine how their quality of life was impacted. The demographics broke down to 47 who underwent both FFS and SRS, 28 who underwent FFS alone, 25 who underwent SRS alone, and 147 who underwent neither, for a total of 247. When compared to the general population of women, FFS was associated with positive physical, mental, and social functioning regardless of whether or not SRS was done. SRS gave a positive result in terms of physical functioning and role, improved physical pain, and vitality. Those without FFS or SRS had poorer mental health and emotional roles than the general female population, but those who had undergone either surgery were equivalent or slightly better in mental health and emotional roles when compared to the general population. (Ainsworth)

A meta-study was conducted to assess whether hormone treatment and/or SRS resulted in a positive life outcome. Studies from 1966 to 2008 were evaluated, which may be somewhat of a broad net – after all, transgender care has improved tremendously just in the last 15 years, let alone the last 48. Starting with 918 possible studies, the authors of this study boiled down to the 28 most relevant and scientifically sound studies, which included a total of 1,091 transwomen and 801 transmen. The majority of these studies were European. The cross-study results showed that 80% of those undergoing SRS reported significant improvement in their gender dysphoria and quality of life (84% for transwomen, 78% for transmen). In general they reported “good satisfaction” with their new gender role, physical appearance, and suffered from no doubts about their gender transition. Satisfaction with their physical sex characteristics was significantly higher after SRS. Most had no regrets about transition; however one study showed 3 out of 17 individuals regretting their decision, with 2 of those 3 attempting to reverse the procedure. In terms of psychiatric symptoms, 78% saw improvement after SRS. Psychiatric commodities (depression, sleep disorders, substance abuse, eating disorders, etc.) were prevalent at a rate of 71% on a lifetime basis, with 39% currently having a current problem. Only a third were undergoing hormone treatment, however. Suicide attempt rates decreased after SRS, but remained higher than those of the general population. Overall, however, 4 of 24 studies which examined the quality of life reported a worsening of quality of life. This was also reported to be largely due to social isolation, unemployment or underemployment, and poverty. Satisfaction with transition was found to be age-dependent, with younger transition ages correlating to greater happiness. In terms of sexual satisfaction, 63% of transwomen and 80% of transmen reported improvement. One study of 28 did conclude sexual satisfaction would decrease. (Murad)

A study of 15 transwomen and 15 transmen who had undergone SRS at least 2 years prior found that 28/30 were satisfied with their results. Social quality of life improved in 21/30, and sexual quality of life improved in 25/30. No patients were dissatisfied with their results, none reported a worsening of social interactions, and only 1 transwoman reported a worsening of sexual relations. Ten reported improved family relationships, and 1 reported worsened family relationships. Twenty patients were able to reach orgasm easier than before, 4 had a more difficult time. In general, transmen had better relationships and better health than the transwomen. However, transmen were more likely to feel embarrassment due to their physical condition. (Parola)

2011

A study from the Netherlands examined the long-term mortality rate of transsexuals who received hormones. A total of 966 transwomen and 365 transmen were followed for a median of 18.5 years and a minimum of 1 year. For transwomen, the following statistics were compiled: lung and blood cancers were higher than the general population, as was ischemic heart disease (speculation by Una: possibly due to the fact that transwomen are much more likely to be smokers than the general population). No cases of breast cancer were reported. Most transwomen were on ethinyl estradiol, which is not commonly prescribed since the mid-2000’s, and which was found to be a contributing factor. The rate of AIDS deaths was 30 times the general population, the rate of illegal drug-related death 13 times the general population, and the rate of suicide nearly 6 times the general population. For transmen digestive tract and blood cancers were higher than the general population, as was genitourinary system disease. The rate of illegal drug-related death was 25 times the general population, and the rate of suicide nearly 2 times the general population. It should be noted that the overall death rate due to cancer was nearly identical to the general population. What is important to note is that in terms of suicide rates, no comparison was made with a control group of untreated transsexuals, so no clear conclusions can be drawn as to how effective transsexual hormone treatment is for changing suicide rates. (Asscheman)

A Swedish study of 191 transwomen and 133 transmen over 1973-2003 who had undergone SRS found that they were 2.8 times as likely to die from any cause than the general population, 2.5 times as likely to die from cardiovascular disease, and 2.1 times as likely to die from cancer. More tellingly, they were 19.1 times as likely to die by suicide. They were also 7.9 times as likely to have made a suicide attempt. However, when the data was limited to the last 15 years of the study, all of these mortality rates deceased substantially. For example, those who transitioned in the 1988-2003 period had an overall mortality risk 1.9 times greater than the general population, and double the risk of a suicide attempt. This difference is likely due to the advancements in treating transsexuals over the latter quarter of the 20th century. Transmen fared better in all categories than transwomen. The study noted that the increase in cancer was not likely to be due to hormone treatment, and due to the locations of the cancer it is likely to be related to the increased rate of smoking (well-known) among transsexuals. Transwomen had a higher rate of criminal behavior than female controls, but less than male controls. (Dhejne)

A Belgian study of 49 transmen with an average time post-SRS of 8 years (minimum 2; maximum 22) found they had high physical functioning, high physical role acceptance, and a general health equal to that of the general population. Their social functioning was good, and their emotional functioning was between that of male and female controls. Two areas where they lagged were mental health and vitality, although only vitality was statistically significant. Of 28 who responded, 18 were either satisfied or very satisfied, and 5 were neutral in terms of their sexual satisfaction. More than 93.7% were satisfied or very satisfied with their hysterectomies and mastectomies, 88.8% were satisfied or very satisfied with their phalloplasties, and 67.8% were satisfied with their erection prostheses. (Wierckx)

2012

A Spanish study of 113 transwomen and 74 transmen (120 on hormones and 67 not having had hormones) found that transsexuals who were on hormones had lower levels of social avoidance and distress, and significantly lower levels of anxiety and depression. In fact, in terms of anxiety the number of subjects who were rated in the “normal” category increased from 39% to 67%, and in terms of depression the number who rated in the “normal” category increased from 69% to 92% as a result of hormone therapy. A comparison of the subset undergoing hormone therapy, dividing into those who had SRS and those who hadn’t, found that while social avoidance and distress did decrease it was at low significance. Furthermore, anxiety and depression did not significantly change as a result of SRS. No evaluation of suicides or attempts was made. (Gómez-Gil, Esther et al., 2012)

A French study focusing just on hormone treatment examined the change in the quality of life of 31 transwomen and 30 transmen. It was noted right away in this study that 43.3% of the subjects were unemployed, which one would expect to skew quality of life metrics. In general, the transsexual subjects were slightly poorer than the controls in terms of physical and social function, emotional and physical roles, and body pain. They were equivalent in terms of vitality, and slightly better than the controls in terms of mental health and general health. When transsexuals who were not on hormones were examined independently, their quality of life metrics were much poorer than both the controls and transsexuals on hormones, except in the areas of physical function (equivalent to all transsexuals), body pain (equivalent to all transsexuals), and general health (equivalent to the controls and all transsexuals). When just the transsexuals taking hormones were compared to controls their scores were similar, excepting that physical role and body pain was poorer, and mental health, vitality, and general health were better. (Gorin-Lazard)

A Scottish study of 889 transgender or gender fluid persons asked several questions of each group and subgroup of transgender persons regarding their satisfaction level with different aspects of the transition process.

  • In terms of satisfaction with life in general, those who were proposing to undergo transition were 31% likely to be satisfied, and 50% dissatisfied. Those undergoing transition were 54% likely to be satisfied, and 28% were dissatisfied. Among those who had completed gender transition, 75% were satisfied, and 11% were dissatisfied. (N=738)
  • In terms of satisfaction with their body, those wanting to transition were only 2% satisfied or very satisfied and 88% dissatisfied or very dissatisfied. Those undergoing transition were 22% satisfied or very satisfied, and 63% dissatisfied or very dissatisfied. Those who had completed transition were 77% satisfied or very satisfied, and 15% dissatisfied or very dissatisfied. (N=680)
  • The effect of hormones on body satisfaction was highly significant, with 85% reporting greater satisfaction, and only 2% reporting less satisfaction. (N=417) The effect of hormones on satisfaction with life in general was also highly significant, with 82% reporting greater satisfaction, and only 2% reporting less satisfaction. (N=398)
  • Non-genital surgery led to 87% reporting they were more satisfied with their bodies, versus 2.6% being less satisfied. (N=193) And 90% of those undergoing genital surgery were more satisfied with their bodies, versus 3.7% being less satisfied.(N=136)
  • Non-genital surgery led to 88% reporting they were more satisfied with life in general, versus 3.9% being less satisfied.(N=182) And 83% of those undergoing genital surgery were more satisfied with their bodies, versus 3.8% being less satisfied. (N=131)
  • Experiences with gender identity clinics (GIC) were less positive. Overall, 47% reported attending a GIC had a positive effect on their lives, whereas 30% reported a mixed effect, and 11% reported a negative effect on their lives. (N=297)
  • Finally, in terms of quality of life, 78% reported that recognizing their gender identity OR transitioning had improved their quality of life, compared to 9% who felt it had worsened their quality of life. (N=499)

(McNeil)

A Belgian study examined 148 transwomen and 107 transmen at a variety of states of their transition to determine their overall quality of life relative to the general population. A total of 64% of transwomen and 68% of transmen in the study had undergone SRS, and 95% of transwomen and 97% of transmen were undergoing hormone treatment. For the transwomen, hormone use was associated with positive outcomes in their satisfaction of their physical body and general health.  (Motmans)

2013

An Italian study examined the effect of hormones on the quality of life of 107 transsexuals (78 transwomen and 29 transmen). Depression impacts were the most dramatic, with significant decreases after hormone treatment (p < .001) as determined by two different metrics. Other disorders which decreased significantly (p < .001) were obsessive-compulsive tendencies, interpersonal tendencies, anxiety, and overall mental instability. In fact every single metric of mental health improved, at levels from p < .023 to p 1)

Another Italian study of 70 transsexuals (45 transwomen, 25 transmen) both before and after hormone therapy found that hormone therapy greatly reduced their cortisol awakening response (a measure of your body’s attempt to anticipate stress) and perceived stress (p < .001 for both cases). (Colizzi2)

A study of 119 transwomen and 74 transmen found that their relative quality of life was linked to three significant factors: family support, being employed, and having hormone treatment. In terms of just hormone treatment, physical improvements were seen with a significance of p < .05, social improvement were seen with a significance of p < .01, and psychological improvements were seen with a significance of p < .001. Overall, quality of life was improved with a significance of p < .05. (Gómez-Gil, Esther et al., 2013)

A study of 60 Thai transwomen (kathoey) and examining their overall well-being compared those taking hormones with those not taking hormones to see if there was any trend towards hormone therapy yielding a better quality of life. While acceptance by family and their level of cross-dressing had impacts on their mental health and well-being, hormone use did not significantly impact their mental or physical scores (in fact, hormone use led to a slight but non-significant decline in these scores overall). (Gooren, 2013)

A French study of 36 transwomen and 31 transmen compared the effects of hormone treatment on self-esteem, mood, and quality of life. Self-esteem increased significantly on hormone treatment (p < .003), depression decreased significantly (p < .05), and quality of life increased in two different metrics, one of them significantly (p < .02). One interesting finding of this study was that sexual orientation was much more weighted towards same-gender relations for those on hormones than those without. (Gorin-Lazard, 2013)

2014

A study of 243 Australian transsexuals found that 59% of them had depressive symptoms, 44% reported a prior suicide attempt, and 69% reported having been victimized as a result of their gender identity. A mildly significant trend was seen between having depression and having been victimized for gender identity. Social support was reported as being much lower than that of the general population. All other factors aside, it was found that depression was least among those who had undergone hormone therapy and/or sexual reassignment surgery (SRS). However, the study did not attempt to determine a causal link between hormone use and/or SRS and an improvement in quality of life. (Boza et al)

A group of 208 transgender and genderqueer men were given a cross-sectional survey approved by the Human Subjects Institutional Review Board of San Francisco State University. Participants were recruited at San Francisco Bay Area transgender community events from 2005-2006. Participants who had not started hormone therapy or undergone chest reduction surgery were reported to have the highest rates of anxiety, anger, depression, and body dissatisfaction. Whereas those having both testosterone therapy and chest reduction surgery were reported as having the lowest rates of anxiety, anger, depression, and body dissatisfaction. Among those who had started hormone therapy and noticed mood changes (n=109):

  • 43% stated they felt happier/less depressed since beginning testosterone therapy.
  • 31% stated that they were feeling more assertive/more confident.
  • 30% stated they felt calmer/more relaxed/less anxious.
  • 28% described feeling less emotional/more balanced/more stable/less mood swings.
  • 17% also noted that they cried less frequently on testosterone.

Thirty-one percent described temporary mood effects lasting 6 months to 24 months from the start of their testosterone use. In addition:

  • 26% stated that they were angrier/more irritable/quicker to get angry. Of these, 60% explained that the increase in anger was a temporary effect, which later subsided.
  • 17% described experiencing temporary mood swings, which disappeared either after their dose of testosterone was raised, or after they switched from every-other-week injections to weekly injections.

The overall conclusion: “Consistent with our overall hypothesis, the results provide clear evidence that testosterone and CRS are associated with indicators of more positive mental health (fewer symptoms of anxiety and depression and less anger) and with greater body satisfaction in FTMs. Although both testosterone alone and testosterone plus CRS were related to fewer symptoms of anxiety and depression and less anger compared with neither treatment, contrary to our hypothesis, the T-only and the T+CRS groups did not differ on these three variables. As hypothesized, T+CRS participants did demonstrate less body dissatisfaction than did those in the T-only and Nt groups. However, participants in the T-only group did not differ from the Nt group on body dissatisfaction. Taken together, these results indicate that testosterone treatment is associated with a positive effect on mental health, while CRS seems to be more important for the alleviation of body dissatisfaction in FTMs. (Davis et al)

A study published October, 2014 in the journal Pediatrics found that of 55 transgender young adults who had previously received puberty blockers saw significant improvements to the psychological functioning. The 22 transgirls and 33 transboys who were treated were assessed before the start of puberty blockers, at the point where hormone therapy was started and the blocker use ended, and 1 year after sex reassignment surgery (SRS). While puberty blockers did not necessarily relieve gender dysphoria, they were found to significantly improve the overall body image of the youths. This improvement was sharply better after administration of hormone therapy and SRS. Other psychological symptoms were greatly reduced. From the study: “Psychological functioning improved steadily over time, resulting in rates of clinical problems that are indistinguishable from general population samples (eg, percent in the clinical range dropped from 30% to 7% on the YSR/ASR30) and quality of life, satisfaction with life, and subjective happiness comparable to same-age peers.” (De Vries et al)

An Italian study of 125 subjects (66 transwomen and 59 transmen) who had not undergone SRS examined how their body acceptance and psychiatric symptoms changed as a result of hormone therapy. After correcting for variables such as age, gender role, cosmetic non-genital surgery, etc., transwomen saw significant improvements in body acceptance, body image, avoidance, depersonalization, and dislike for body parts. Transmen saw improvements, but they were not judged significant. Transwomen saw improved body acceptance with both longer treatment times and greater dosage rates of hormones. The authors note some concern over the lack of significant differences between transmen on and off hormones. (Fisher et al)

A UK study of 25 transmen who had undergone at least one of three different types of genital surgery found that their overall satisfaction with their surgeries rated 8.7-9.4/10, depending upon the type of surgery. None of the 25 patients expressed regret for their surgeries. Note that this study did not specifically ask on overall quality of life, but rather on surgical outcome. (Garcia et al.)

A Belgian study followed the psychological change in 57 transsexuals (46 transwomen and 11 transmen) from their initial consultation through hormone therapy and ultimately to after sex reassignment surgery (SRS). It must be noted that only 42 persons had undergone SRS at the time of the paper’s completion; the rest were pending. Comparing 9 different SCL-90 scores of the general population, pre-treatment transsexuals, transsexuals who underwent hormone therapy, and transsexuals who finished their SRS, profound improvements in their quality of life were seen. The greatest improvement was seen for those who had undergone hormone therapy – there was no significant difference in psychological scores between those on hormone treatment and those undergoing SRS. In terms of overall psychoneurotic distress, hormone therapy was slightly significantly better than surgery. Between the initial presentation and the final consultation drug and alcohol abuse rates plummeted, and social contacts improved. Other metrics such as employability and relationship status were not significantly changed, and sexual activity was reduced. (Heylens et al)

An Italian study examined 45 healthy transmen to determine the physical (primarily) and mental (secondarily) changes associated with hormone therapy. Three different hormone formulations were used, and included injectable and gel methods of delivery. All subjects were evaluated before treatment, at week 30, and at week 54 of treatment. Testosterone was well accepted by the participants, and injectable hormones were found to be the most effective at increasing testosterone levels. Satisfaction with treatment as measured on a visual analog scale showed unanimous agreement among the subject of a very high increase in their perceived quality of life regardless of the testosterone treatment which was used. (Peluci et al)

2015

Seventy-one transsexuals who had sought treatment at a clinic in Germany were evaluated over a long-term follow-up period of 10-24 years (mean=13.8 years). All participants had to have undergone a legal name change and to be living as their transitioned gender full-time. Although all participants were originally on hormone therapy, two had ceased hormone therapy at the time of the survey. All but 2 of the transwomen had undergone full sex reassignment surgery, 8 transwomen had undergone breast augmentation, 6 had undergone larynx surgery, and 2 vocal cord surgery. All of the transmen had undergone breast reduction surgery, and all but 3 had undergone either removal of the ovaries or a hysterectomy. NONE of the participants had any desire for reversal of their transition, and they had very high confidence in their new gender role. From the study: “Overall, participants’ evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. It was described as a‘‘challenge’’or a ‘‘long and difficult road’’ that was worth taking because of its positive implications on future life, at the end of which not everything was different or better without limitations (‘‘you should not believe that […] life is sky blue and you can ride into the sunset with your prince’’). Retrospectively, participants also mentioned what could have been done in a different way. They mainly wished they had begun their sex change earlier in life or that they had completed the treatment more quickly.” Comparison of psychological profiling conducted at their initial consultation and as part of this study showed that of the 10 factors evaluated for the SCL-90-R test, patients improved significantly in every single area except somatization, where a non-significant decline was found. (Ruppin et al)

Una is a professional science researcher and part-time university professor. The reader is encouraged to perform their own follow-up and fact-checking with the references listed below. Unintentional bias may exist in this article, as the author is herself an intersex transsexual woman. No personal, commercial, or academic conflict of interest exists between the author and any authors or institutions cited as references.

References

Ainsworth, Tiffiny A., and Jeffrey H. Spiegel. “Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery.” Quality of Life Research 19.7 (2010): 1019-1024.

Asscheman, Henk, et al. “A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones.” European Journal of Endocrinology 164.4 (2011): 635-642.

Bazarra-Castro, María Ángeles. Etiological aspects, therapy regimes, side effects and treatment satisfaction of transsexual patients. Diss. lmu, 2009.

Boza, Crystal, and Kathryn Nicholson Perry. “Gender-related victimization, perceived social support, and predictors of depression among transgender Australians.” International Journal of Transgenderism 15.1 (2014): 35-52.

Colizzi1, Marco et al. “Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study” Psychoneuroendocrinology 39 (2014): 65—73.

Colizzi2, Marco et al. “Hormonal Treatment Reduces Psychobiological Distress in Gender Identity Disorder, Independently of the Attachment Style” J Sex Med 10 (2013):3049–3058.

Davis, Samuel A., and S. Colton Meier. “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 (2014): 113-128.

De Cuypere, Griet, et al. “Sexual and physical health after sex reassignment surgery.” Archives of Sexual Behavior 34.6 (2005): 679-690.

De Cuypere, G., et al. “Long-term follow-up: Psychosocial outcome of Belgian transsexuals after sex reassignment surgery.” Sexologies 15.2 (2006): 126-133.

De Roche, R., et al. “A team approach to the indication for gender reassignment surgery in transsexuals resulting in long-term outcome improvement.” European Journal of Plastic Surgery 27.1 (2004): 24-28.

De Vries, Annelou LC, et al. “Young adult psychological outcome after puberty suppression and gender reassignment.” Pediatrics 134.4 (2014): 696-704.

Dhejne, Cecilia, et al. “Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden.” PLoS One 6.2 (2011): e16885.

Fisher, Alessandra D. et al. “Cross-Sex Hormonal Treatment and Body Uneasiness in Individuals with Gender Dysphoria” Sex Med 11 (2014): 709–719.

Garcia, Maurice M. et al. “Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience” Transl Androl Urol 3.2 (2014): 156-162.

Gómez-Gil, Esther et al. “Hormone-treated Transsexuals Report Less Social Distress, Anxiety, and Depression” Psychoneuroendocrinology 37 (2012): 662—670.

Gómez-Gil, Esther, et al. “Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery.” Quality of Life Research 23.2 (2014): 669-676.

Gooren, Louis J. et al. “Exploration of functional health, mental well-being and cross-sex hormone use in a sample of Thai male-to-female transgendered persons (kathoeys)” Asian Journal of Andrology 15 (2013): 280–285.

Gorin‐Lazard, Audrey, et al. “Is Hormonal Therapy Associated with Better Quality of Life in Transsexuals? A Cross‐Sectional Study.” The Journal of Sexual Medicine 9.2 (2012): 531-541.

Gorin-Lazard, Audrey et al. “Hormonal Therapy Is Associated With Better Self-esteem, Mood, and Quality of Life in Transsexuals” The Journal of Nervous and Mental Disease 201.11 (November, 2013): 996-1000.

Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

Heylens, Gunter, et al. “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 (2014): 119-126.

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21 thoughts on “Quality of Life in Treated Transsexuals

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  3. lauralee

    Quality of life? Doing any kind of study about this is so difficult when so many variables are at play: time and stage of transition, location and political attitudes, employment, or lack thereof, support groups, family, friends, etc available. Quality of surgeries, marital status before and after transition. stealth or activist?
    level of mental health prior to transition, any co-morbid mental or mental health issues?, etc.

    Anecdotally, my experience has been very positive. I am the person I always knew myself to be: an active, happy, busy, intelligent, woman who is doing what she can to make a difference. My surgical results are wonderful. Everything looks and functions the same as cisgender standard factory equipment. I am blessed to have kept my career, family and have wonderful friends.

    My regrets: it’s difficult living in a world that doesn’t always understand and accept. Many of us are trying to change that and it’s happening although slowly. My other regret: it’s hard to find someone who is willing to date an “out” transgender woman in the ultra-conservative area where I live. But I can’t and won’t be stealth.

  4. Una Post author

    Lauralee – it’s true that quality of life (QOL) is highly subjective, but researchers are able to gain some indication as to general improvements/worsening of life outcomes provided the study is controlled well enough and the sample size large enough. That is one problem with these studies, sample sizes are typically on the small scale, because there simply aren’t so many of us in the first place, and even fewer who are willing to participate in studies. See Lawrence 2006 for a description on how few members of her initial population wished to participate.

    I’d advise reading the studies in detail to see what each study controlled. I don’t have the space here to do that for them all, but I have provided citations.

    Nonetheless, if the haters are going to point to a study here or there as “proof” that we shouldn’t transition, then my goal is to point to a bunch of studies and reply “no, by your own metrics, we should and must transition!”

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