gender reassignment surgery singapore

First sex reassignment surgery

Singapore infopedia.

by Chan, Meng Choo

The first sex reassignment surgery in Singapore was successfully performed on 30 July 1971 at the Kandang Kerbau Hospital (now known as the  KK Women’s and Children’s Hospital ). The operation involved a 24-year-old man and was the first procedure of its kind carried out in Singapore. There had been similar operations done in Singapore, but these mostly involved patients who had both male and female genitalia (hermaphrodites) and the removal of one set of genitalia. 1  The 1971 operation was regarded as the first because it involved a surgical conversion aimed at functionally changing a person’s sex and appearance. 2 Patient and diagnosis The patient was a 24-year-old Chinese Singaporean. Her name was kept secret, but her background was later made public in a book. Born the eldest son in a family of five with two younger sisters, her father was a dentist who was often physically violent with his wife, which caused the patient psychological trauma. As a child, the patient was raised by her grandmother, who dressed her as a female. In her teenage years, she associated with other cross-dressers before frequenting the transgender scene on  Bugis Street  as an adult. 3 From the age of 16, she worked as a sales assistant, a housemaid, in a bank and as a public relations officer in a hotel. She later won second prize in a beauty contest and became a model. While working as a part-time model, she joined a cabaret in 1968 and was known as “Mama Chan”. She also ran a social escort service. 4 Having lived as a woman for some time, in 1969 she first consulted Professor  S. S. Ratnam , a senior lecturer in the  University of Singapore ’s Department of Obstetrics and Gynaecology. She had been suffering from sexual and emotional problems, which led to two suicide attempts. Ratnam explained to her that he had no experience in sex reassignment surgery, but she continued to visit his clinic weekly. After researching the subject of transsexualism and sex reassignment surgeries, Ratnam familiarised himself with the surgical techniques by practising on cadavers. 5 The patient then underwent a psychological analysis by a team of psychiatrists who confirmed that the patient was a transgender who required surgery. 6  The diagnosis required the patient to possess a continual sense of inappropriateness about his or her anatomic sex, a desire to discard his or her genitalia and live as a member of the opposite sex, and the absence of physical intersex symptoms or genetic abnormalities. In addition, the gender confusion (gender dysphoria) must not be caused by other disorders such as schizophrenia. 7  The patient was also cautioned that the surgery would be irreversible, potentially involved a number of complications and required a prolonged follow-up period. 8  A total of six to nine months of medical and psychiatric tests had to be carried out before the patient could take the operation. 9 Legal clearance for the operation was then sought from the Ministry of Health and granted. After consideration of the patient’s psychological profile and the medical expertise involved, with the approval of the ministry, it was decided to proceed with the operation. 10  Operation and impact The operation was performed by Ratnam and two other surgeons from the University of Singapore’s Department of Obstetrics and Gynaecology, Associate Professor Khew Khoon Shin and plastic surgeon R. Sundarason. 11  Photography of the operation was not permitted. Ratnam later described the three-hour operation as a success, with an uneventful post-surgery recovery. 12    After her successful operation, the patient went on hormone treatments 13  and was functionally a woman, though she could not conceive or menstruate. 14  She later married a French man and owned a travel agency in Paris, before moving to England. 15 The July 1971 operation paved the way for sex reassignment surgeries in Singapore and the region. Singapore’s first sex reassignment operation on a woman took place three years later. It was carried out in three stages between August 1974 and October 1977. 16  Female-to-male conversions are more complex and involve several surgical stages. 17  In the 1970s and ’80s, hospitals in Singapore accepted numerous sex change patients from abroad, with foreigners making up around half of all surgeries performed, while the rest were locals and Malaysians. 18   In the years following the operation, a number of legal issues arose for transsexuals – those who had undergone a sex change. The Registry of Marriages implicitly recognised marriages involving a transsexual, as it required only an identity card to prove the different genders of the couple. 19  In 1991, however, a marriage between a transsexual man and a woman was declared void by the  High Court , officially making such marriages illegal in Singapore. 20  It was only in 1996 that the government amended the Women’s Charter to allow transsexuals to marry legally. 21 Author Chan Meng Choo References 1. Yeo, J. (1971, July 31).  First sex change surgery in S’pore .  The Straits Times , p. 17; Tan, W. L. (1971, August 25).  Sex change patient has marriage plans .  The Straits Times , p. 8. Retrieved from NewspaperSG. 2. Tan, W. L. (1971, November 11).  They’re still ‘misters’ despite sex change .  The Straits Times , p. 8. Retrieved from NewspaperSG. 3. Ratnam, S. S., Goh, V. H. H., & Tsoi, W. F. (1991).  Cries from within: Transsexualism, gender confusion & sex change . Singapore: Longman Singapore, pp. 25–26. (Call no.: RSING 616.8583 RAT) 4. Ratnam, S. S., Goh, V. H. H., & Tsoi, W. F. (1991).  Cries from within: Transsexualism, gender confusion & sex change . Singapore: Longman Singapore, pp. 25–26. (Call no.: RSING 616.8583 RAT) 5. Ratnam, S. S., Goh, V. H. H., & Tsoi, W. F. (1991).  Cries from within: Transsexualism, gender confusion & sex change . Singapore: Longman Singapore, pp. 25–26. (Call no.: RSING 616.8583 RAT) 6. Yeo, J. (1971, July 31).  First sex change surgery in S’pore .  The Straits Times , p. 17; Tan, W. L. (1971, August 25).  Sex change patient has marriage plans .  The Straits Times , p. 8. Retrieved from NewspaperSG. 7. Ratnam, S. S., Goh, V. H. H., & Tsoi, W. F. (1991).  Cries from within: Transsexualism, gender confusion & sex change . Singapore: Longman Singapore, p. 4. (Call no.: RSING 616.8583 RAT) 8. Chua, M. (1974, November 7).  Who really needs a sex-change?   The Straits Times , p. 10. Retrieved from NewspaperSG. 9. Lim, S. (1990, May 20).  Legal poser over sex-change transsexuals who get hitched .  The Straits Times , p. 21. Retrieved from NewspaperSG. 10. Tan, W. L. (1971, November 11).  They’re still ‘misters’ despite sex change .  The Straits Times , p. 8. Retrieved from NewspaperSG. 11. Tan, W. L. (1971, August 25).  Sex change patient has marriage plans .  The Straits Times , p. 8. Retrieved from NewspaperSG. 12. Yeo, J. (1971, July 31).  First sex change surgery in S’pore .  The Straits Times , p. 17. Retrieved from NewspaperSG. 13.  Second sex change operation in S’pore . (1971, November 5).  The Straits Times , p. 15. Retrieved from NewspaperSG. 14.  Why sex-change patients set up homes overseas . (1975, August 10).  The Straits Times , p. 5. Retrieved from NewspaperSG. 15. Ratnam, S. S., Goh, V. H. H., & Tsoi, W. F. (1991).  Cries from within: Transsexualism, gender confusion & sex change . Singapore: Longman Singapore, p. 26. (Call no.: RSING 616.8583 RAT);  She tried to commit suicide.  (1992, January 18).  The New Paper , p. 20. Retrieved from NewspaperSG. 16. Kwee, M. (1974, October 20).  S’pore’s first sex change woman .  The Straits Times , p. 1. Retrieved from NewspaperSG. 17.  Why sex-change patients set up homes overseas . (1975, August 10).  The Straits Times , p. 5. Retrieved from NewspaperSG. 18. Chong, G. P. (1986, November 3).  Sex-change cases can get new ICs.   The Straits Times , p. 13. Retrieved from NewspaperSG. 19. Lim, S. (1990, May 20).  Legal poser over sex-change transsexuals who get hitched .  The Straits Times , p. 21. Retrieved from NewspaperSG. 20.  Sex-change pairs can’t marry . (1991, September 26).  The New Paper , p. 11. Retrieved from NewspaperSG. 21. Goh. T. T. (1996, January 26).  They were allowed to wed before.   The New Paper , p. 9; Gwee, E. (1996, August 30).  ‘I do’ – and no need to state gender at birth .  The Straits Times , p. 6. Retrieved from NewspaperSG. Further resources Cheow, X. Y., & Fung, E. (2007, March 7).  Born in the wrong body .  The Straits Times , p. 114. Retrieved from NewspaperSG. Chong, G.P. (1986, November 3).  Sex-change cases can get new ICs.   The Straits Times , p. 13. Retrieved from NewspaperSG. Fifth sex-change operation a success . (1972, September 11).  The Straits Times,   p. 6. Retrieved from NewspaperSG. Sex change man signs statutory declaration affirming that he is now a woman . (1972, April 16).  The Straits Times , p. 6. Retrieved from NewspaperSG. Tan, K. H., & Tay, E. H. (Eds.). (2003).  The History of Obstetrics and Gynaecology in Singapore . Singapore: Obstetrical & Gynaecological Society of Singapore: National Heritage Board. (Call no.: RSING q618.095957 HIS) Tan, W. L. (1971, August 31).  Man-made woman may not get marriage licence .  The Straits Times , p. 6. Retrieved from NewspaperSG. The information in this article is valid as at  2016  and correct as far as we are able to ascertain from our sources. It is not intended to be an exhaustive or complete history of the subject. Please contact the Library for further reading materials on the topic.

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7 Questions About Trans Issues in Singapore You Were Embarrassed To Ask

More than any other time in recent history, trans-related issues have seen increased discourse in Singapore. The year started with  a local transgender student , accusing the Ministry of Education of intervening in her hormone therapy treatment (HRT). Then, more recently, 24-year-old NUS undergraduate Dana Teoh has been thrust into public scrutiny for an  opinion piece  that centres around her frustration at the “woke movement” in Singapore. Teoh’s article has since drawn  mixed reactions  from the Internet, with some criticising her for a lack of sensitivity in addressing the issues faced by an already-marginalised group in Singapore—the transgender community.

Both issues highlight the increasingly pressing need to address a question that has yet to be dealt with properly in mainstream media: what is being transgender really like in Singapore? 

Mainstream awareness of transgender issues 

Local  attitudes towards LGBTQ issues remain largely conservative , according to the latest World Values Survey published in February by the Institute of Policy Studies. 

Even then, such surveys are not entirely representative of attitudes towards the trans community in Singapore. The  lack of official documentation  on the community – ranging from basic things like its estimated size to more critical issues such reporting on violence experienced – contributes towards a general lack of awareness of transgender issues. 

Poorly-understood issues that are indispensable from the trans experience include the transitioning process, the procedures one might choose to undergo, and the current laws in place for those seeking medical care for transitioning. 

This story aims to unpack these issues, and delve deeper in its implications for a community of individuals in Singapore that are slowly, but surely, emerging into the light of public discussion.

1) What is the history of the trans community in Singapore?

The transgender community has always played a part in Singapore’s history. 

The Bugis people, an Indonesian ethnic group, were one of the  first people to settle in Singapore  after the British began to transform the island into a trading hub. What is less well-known, however, would be the fact that the  Buginese community is known to be accepting of five types of genders . 

Besides the two genders that make up the “traditional” binary gender system, the Bugis people recognised the  calalai  (analogous to transgender men or masculine women), the  calabai  (analogous to transgender women or effeminate men), and the  bissu , who were androgynous shamans with both male and female characteristics. 

One of the first places the Bugis people settled in after arriving in Singapore was the area that stretched from Kampong Glam up to Rochor River. Today, areas occupied by landmarks such as the Bugis MRT station, Bugis Junction and Bugis Street pay homage to the district’s connection to the Buginese through their names. 

In an interesting coincidence, from the 1950s to the 1980s, the same area became home to a  vibrant community of transgender  individuals.  Bugis Street drew nightly crowds of foreign servicemen, sailors and tourists drawn to all the charms the area had to offer: alfresco bars, hawker stalls and of course, transgender women. 

For a brief blip in time, Singapore had more to offer than the sanitised shopping malls and the fancy skyscrapers that adorn Marina Bay, thanks to the transgender women who defined Bugis Street. The area has since been neatly cobblestoned over, and rebranded as another tourist-hub-cum-shopping mecca. One look at Bugis Street today, and one could be forgiven for being none the wiser about its riotous, colourful past as a hub for the local trans community. 

2) What does gender dysphoria mean?

Gender dysphoria, or the distress experienced when one feels a mismatch between their gender identity and biological sex, is typically brandished in debates about whether being trans can be considered a mental disorder. 

While gender dysphoria is categorised as a mental disorder, the condition refers to “the  distress  experienced from being transgender, and not the state of being transgender itself”.

For many experiencing gender dysphoria, ‘transitioning’, or adopting the outward characteristics (be it in terms of clothing, behaviour, or pronouns) of the gender identity they feel most comfortable with, remains one of the most effective ways to alleviate the condition. 

However, while it is common for trans individuals to experience some form of gender dysphoria, particularly when they have yet to transition in any way, not all of them do. 

To transgender woman Anabel Goh (not her real name), transitioning was simply a “procedure” for her to get a gender marker change—a decision that was “expedited” by the arrival of her enlistment letter for National Service, and not any sense of gender dysphoria. 

3) What’s the difference between sexual orientation, gender expression, and gender identity? 

To put it simply, gender identity refers to one’s personal, internal sense of being male, female, both, or neither. Being transgender boils down to identifying with a gender that deviates from the one’s biological sex. Non-binary people, or those whose gender identity lies outside of the binary (male or female) are also considered part of the trans community. 

“Being transgender is defined by how you  feel ,” stresses Goh. 

With this in mind, it’s easy to see how sexual orientation, or one’s pattern of emotional, sexual and romantic attraction to a particular gender, is entirely separate from gender identity. On top of being transgender, one can also identify as heterosexual, homosexual, or bisexual—just to name a few. 

Gender expression, however, can be a trickier concept to grasp. Contrary to popular opinion, the way in which one behaves or presents themselves, specifically within the standard categories of femininity and masculinity, does not necessarily have to align with one’s internal sense of gender identity. 

For example, a person who identifies as a heterosexual male can still ‘present’ femininely, such as by occasionally wearing skirts, putting on makeup on painting their nails. Physical appearance, as well as mannerisms and behaviour, all contribute towards one’s gender expression. 

Likewise, non-binary people can also vary their gender expression based on what feels most right to them. 

“Just because they are non-binary doesn’t mean they have to present androgynously (partly male and partly female in appearance),” says 19-year-old student Eljiah Tay, who identifies as non-binary.  

4) What is this pronoun thing?

For many heterosexual, cisgender individuals, it might be easy to feel like one is treading around landmines when learning the correct way to refer to trans individuals. 

For many trans individuals, however, being misgendered, or spoken or referred to with language that does not correspond with one’s gender identity, can worsen or excavate long-buried feelings of gender dysphoria. 

“When you misgender someone on purpose, you are affirming what  you  think they  should  be, instead of acknowledging who they are, and how they came to be who they are, at present,” says 24-year-old NUS undergraduate Lune Loh, who identifies as a transgender lesbian. 

“Correct pronoun usage [is] a mode of care—you  care  for your friends by referring to them in a manner they feel safe and comfortable with, that does not make them relive the trauma of a gender they do not feel right with,” Loh adds. 

5) What does transitioning mean?

While the concept of transitioning may seem straightforward, there are multiplicities to its meaning that often escape the attention of the wider community. 

For starters, transitioning does not always entail going under the knife, the injection of hormones or even a change of clothes. 

One can choose to transition in two primary ways: social, or medical. The former refers to publicly ‘affirming’ one’s gender identity, typically by adopting a new name and pronouns, or tweaking one’s mannerisms, behaviour and dressing to align with the gender identity that one feels at peace with. One can be considered to have transitioned, even without having gone through any form of surgery or hormone treatment. 

Medical transitioning, however, can range from receiving hormone injections, through a process known as hormone replacement therapy (HRT), to going for sex reassignment surgeries, or what is more commonly referred to as gender confirmation surgery in the trans community. 

Even then, surgeries vary in their level of complexity, with some transgender men choosing to remove their breasts (mastectomy, or ‘top’ surgery) and female reproductive organs (hysterectomy, or ‘bottom’ surgery), while opting to skip procedures for penis construction, such as  metoidioplasty or phalloplasty . 

Yap Wei Xin, a 27-year-old transgender man, is one such individual. At 23, he had flown to Thailand on his own for mastectomy and hysterectomy procedures, which had set him back roughly SGD$14,000 in total. 

For Yap, the multiple surgical processes required for the creation of a penis, as well as the relative lack of credible information and advanced technology for metoidioplasty and phalloplasty procedures, were reasons why he did not go through with either up till that point. 

The high costs attached to medical transitioning, be it for HRTs or surgical procedures, as well as the need for parental consent before undergoing most of these processes, make up some of the main barriers in the transitioning process of many trans individuals. 

Tay, who is interested in undergoing top surgery, cites not having come out to their family yet as one of the reasons for not having undergone any form of medical transition. 

In Singapore, the minimum age for one to  start HRT  without having to obtain parental consent first is 21, while those under 17 are barred from starting any form of HRT. 

Individuals are also required to undergo psychiatric evaluations to certify that they are of sound mind before they can begin HRT, or undergo any form of surgical procedures. This applies even if one were to  receive treatment abroad . 

6) What are gender confirmation surgeries?

Singapore is no stranger to gender confirmation surgeries. On 30 July 1971, a then-24-year-old Singaporean man made history as the  first person to successfully undergo a sex reassignment surgery  in Singapore. The operation gave rise to a few legal issues for trans individuals who have medically transitioned, such as the right for them to marry legally following a gender marker change. 

Although not all trans individuals opt for them, surgical procedures can be a crucial step in the affirmation of one’s gender identity and overall transition process. 

“Every day, I fall in love with myself; everyday, I live my fairy-tale life,” says Goh, on having transitioned in every way she sees fit. 

However, Loh believes more can be done towards providing local trans individuals with access to the estimated costs of the different “chemical and surgical means of transitioning”. 

The myriad procedures available, for both male-to-female and female-to-male procedures, as well as the differences and trade-offs between specific forms of procedures, remain poorly-documented in local health resources. 

Post-operation realities also remain an area of low documentation outside of transgender pages and support groups. For Yap, unsightly scarring was a concern that he struggled with after his mastectomy procedure. Beyond receiving treatments to reduce the scarring, there was “not much the doctor could do”. 

Hormone blockers and hormone therapy treatment

In December 2020, the High Court of the United Kingdom (UK) ruled to ban trans individuals under 16 from receiving access to “puberty blockers and cross-sex hormones”, on the grounds that those under 16 would be “unlikely to give informed consent” for receiving medical care aimed at helping them medically transition. 

The ruling came after 23-year-old Briton Keira Bell launched legal proceedings against a national gender health clinic for inadequate levels of investigation and therapy prior to her decision to transition to a male using puberty blockers. Also known as hormone blockers, puberty blockers put a pause on puberty-inducing hormones like estrogen and testosterone in trans children or teenagers. 

The UK High Court’s decision aligns with the current laws regarding HRT for trans individuals in Singapore, which place parental consent at the core of medical transitioning. 

On the age requirement of 21 years, Loh says: “[In practice,] many adults past [the age of] 21 are still at the mercy of their parents’ authority and rules. 

Thus, with regards to puberty blockers, I do think children and teenagers should be given the choice whether or not to use them… This must be done with [them] knowing all their terms, [as well as the] potential risks and consequences.” 

The age requirement also gives rise to a conundrum for trans children and teenagers who wish to transition medically, but have already gone through puberty and face a limit to how much HRT can reverse the process. 

How Diverse Have Singapore’s Politicians Been Over The Past 20 Years?

Having started HRT well into adulthood, Yap shares that while he did become slightly taller and hairier from his regular testosterone injections, it would be impossible for him to grow much much further as “[his] bones have reached the growing limit”. 

To circumvent this problem, some trans Singaporeans under 21 are procuring hormonal medication online , which cannot be proven to be authentic or safe for consumption. 

To Tay, the conversation about hormone blockers should be directed towards addressing “structural concerns”, such as the lack of adequate information on gender identity issues, and providing young trans individuals with the resources they need to make informed decisions, instead of debating about whether they are capable of making such decisions. 

Besides helping trans individuals make more informed decisions about their gender identity, providing access to more inclusive education to all can also help to debunk certain misconceptions held by non-trans individuals, such as the notion that these decisions are “irrational”, notes Tay. 

7) Why should I care about Trans issues?

Life after transitioning is not a bed of roses for the trans community.

The use of shared, gendered spaces remains one of the biggest challenges faced by trans individuals who transition in ways that do not immediately translate to a perceivable change in their outward appearance. 

In Singapore, there are currently no laws in place to enforce sex-specific use of public restrooms. However, this does not exempt trans individuals, particularly those who appear to be androgynous or are in the midst of receiving HRT, from adverse public reactions, ranging from microaggressions to even censure, when using public restrooms. 

Yap recalls feeling apprehensive of making the switch to male public restrooms, even after his gender confirmation surgeries. For as long as one month after his surgeries, he had stuck to using female restrooms. 

“I do get stares from other ladies in the restroom—some even ask me whether I am a girl,” says Yap, who would just “go with it and say yes”, for fear of being probed further. 

According to Yap, a push from one of his friends is a reason why he eventually found the courage to start using male restrooms. 

“I was still going back and forth between the ladies’ and the gents’ [restrooms], until my friend found out and said: ‘You’re a guy, right?’ I said yes, and she said: ‘Okay, then from now on don’t you dare go [to the] ladies; I will judge you!’,” Yap laughs. 

At that point in time, his voice was also getting deeper from the HRT he was receiving, giving him the confidence he needed to start using men’s restrooms. 

With so many considerations in mind, the only option that remains for trans individuals still in the process of transitioning medically is often to simply opt for unisex, wheelchair-accessible restrooms—an option that is not always available. 

At Loh’s residential college at NUS, there are only about two to three wheelchair-accessible bathrooms in the whole building. As part of a special housing arrangement with the college, she is allowed to use such bathrooms, but with a catch—she still has to stay on the mixed-gender floors of the college, and on the ‘male’ side of the floor. 

“There’s no way I can be placed on an all-female floor—[the] NUS housing policy would not accede to that,” explains Loh. 

Transitioning can also be a complicated and often painful process for those still receiving education in government-funded schools. 

Tay, who recently completed their studies at a local junior college (JC), recounts how they used to get into trouble at school for their reluctance to don their skirt, which remains part of the gendered uniforms that school-going students in Singapore, from primary school all to the way up to JC, are required to wear. 

To avoid wearing a skirt, Tay would try to be in their Physical Education attire as much as possible. Even then, they would still be chided by more “picky” teachers and forced to put on a skirt. 

In Secondary Four, a teacher of Tay’s had addressed them indirectly in front of hundreds of other students in a lecture theatre. 

“[She] said: ‘As long as you’re wearing a skirt, I’ll take that you’re a girl. If you want to be a guy, wait for your next life.’ 

To face transphobia from [a teacher that I respected] really took me aback, and destroyed my trust [in] anybody with authority in the school,” Tay shares. 

Working towards a more trans-inclusive society 

Transgender individuals have always been a part of our society. Despite shifts towards more progressive values in recent years, more has to be done to provide trans individuals in Singapore with the avenues to voice their very real concerns, born from their very real “experiences, histories, traumas, dreams, and desires”, as Loh puts it. 

According to the NUS undergraduate-led research report entitled  Cisgender Students’ Attitudes and Beliefs towards Transgender Individuals and Trans-Inclusive Efforts , there are three main aspects to building a more trans-inclusive community: Model, Educate and Collaborate. 

Besides being changemakers in terms of trans-inclusive efforts like adopting the use of trans individuals’ preferred pronouns, as well as making strides to include trans voices in policymaking, the report advocates for correcting common misconceptions about the trans community—which is exactly what this story hopes to achieve.

Ignorance breeds misunderstanding, which in turn devolves into hate and violence if left to fester. 

The trans community may face many battles in their daily lives, but this is one that the rest of us can ride alongside with them into—if we could just care to ask, and listen.

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Travis amengual.

1 Department of Psychiatry and Behavioral Sciences, Northwestern Medicine, Chicago, IL, United States

Kaitlyn Kunstman

R. brett lloyd, aron janssen.

2 The Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States

Annie B. Wescott

3 Galter Health Science Library, Northwestern University, Chicago, IL, United States

Associated Data

The original contributions presented in this study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Transgender and gender diverse (TGD) are terms that refer to individuals whose gender identity differs from sex assigned at birth. TGD individuals may choose any variety of modifications to their gender expression including, but not limited to changing their name, clothing, or hairstyle, starting hormones, or undergoing surgery. Starting in the 1950s, surgeons and endocrinologists began treating what was then known as transsexualism with cross sex hormones and a variety of surgical procedures collectively known as sex reassignment surgery (SRS). Soon after, Harry Benjamin began work to develop standards of care that could be applied to these patients with some uniformity. These guidelines, published by the World Professional Association for Transgender Health (WPATH), are in their 8th iteration. Through each iteration there has been a requirement that patients requesting gender-affirming hormones (GAH) or gender-affirming surgery (GAS) undergo one or more detailed evaluations by a mental health provider through which they must obtain a “letter of readiness,” placing mental health providers in the role of gatekeeper. WPATH specifies eligibility criteria for gender-affirming treatments and general guidelines for the content of letters, but does not include specific details about what must be included, leading to a lack of uniformity in how mental health providers approach performing evaluations and writing letters. This manuscript aims to review practices related to evaluations and letters of readiness for GAS in adults over time as the standards of care have evolved via a scoping review of the literature. We will place a particular emphasis on changing ethical considerations over time and the evolution of the model of care from gatekeeping to informed consent. To this end, we did an extensive review of the literature. We identified a trend across successive iterations of the guidelines in both reducing stigma against TGD individuals and shift in ethical considerations from “do no harm” to the core principle of patient autonomy. This has helped reduce barriers to care and connect more people who desire it to gender affirming care (GAC), but in these authors’ opinions does not go far enough in reducing barriers.

Introduction

Transgender and gender diverse (TGD) are terms that refer to any individual whose gender identity is different from their sex assigned at birth. Gender identity can be expressed through any combination of name, pronouns, hairstyle, clothing, and social role. Some TGD individuals wish to transition medically by taking gender-affirming hormones (GAH) and/or pursuing gender-affirming surgery (GAS) ( 1 ). 1 The medical community’s comfort level with TGD individuals and, consequently, their willingness to provide a broad range of gender affirming care (GAC) 2 has changed significantly over time alongside an increasing understanding of what it means to be TGD and increasing cultural acceptance of LGBTQI people.

Historically physicians have placed significant barriers in the way of TGD people accessing the care that we now know to be lifesaving. Even today, patients wishing to receive GAC must navigate a system that sometimes requires multiple mental health evaluations for procedures, that is not required of cisgender individuals.

The medical and psychiatric communities have used a variety of terms over time to refer to TGD individuals. The first and second editions of DSM described TGD individuals using terms such as transvestism (TV) and transsexualism (TS), and often conflated gender identity with sexuality, by including them alongside diagnoses such as homosexuality and paraphilias. Both the DSM and the International Classification of Diseases (ICD) have continuously changed diagnostic terminology and criteria involving TGD individuals over time, from Gender Identity Disorder in DSM-IV to Gender Dysphoria in DSM-5 to Gender Incongruence in ICD-11.

In 1979, the Harry Benjamin International Gender Dysphoria Association 3 , renamed the World Profession Association for Transgender Health (WPATH) in 2006, was the first to publish international guidelines for providing GAC to TGD individuals. The WPATH Standards of Care (SOC) are used by many insurance companies and surgeons to determine an individual’s eligibility for GAC. Throughout each iteration, mental health providers are placed in the role of gatekeeper and tasked with conducting mental health evaluations and providing required letters of readiness for TGD individuals who request GAC ( 1 ). As part of this review, we will summarize the available literature examining the practical and ethical changes in conducting mental health readiness assessments and writing the associated letters.

While the WPATH guidelines specify eligibility criteria for GAC and a general guide for what information to include in a letter of readiness, there are no widely agreed upon standardized letter templates or semi-structured interviews, leading to a variety of practices in evaluation and letter writing for GAC ( 2 ). To our knowledge, this is the first scoping review to summarize the available research to date regarding the evolution of the mental health evaluation and process of writing letters of readiness for GAS. By summarizing trends in these evaluations over time, we aim to identify best practices and help further guide mental health professionals working in this field.

The review authors conducted a comprehensive search of the literature in collaboration with a research librarian (ABW) according to PRISMA guidelines. The search was comprised of database-specific controlled vocabulary and keyword terms for (1) mental health and (2) TGD-related surgeries. Searches were conducted on December 2, 2020 in MEDLINE (PubMed), the Cochrane Library Databases (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOhost), Scopus (Elsevier), and Dissertations and Theses Global (ProQuest). All databases were searched from inception to present without the use of limits or filters. In total, 8,197 results underwent multi-pass deduplication in a citation management system (EndNote), and 4,411 unique entries were uploaded to an online screening software (Rayyan) for title/abstract screening by two independent reviewers. In total, 303 articles were included for full text screening ( Figure 1 ), however, 69 of those articles were excluded as they were unable to be obtained online or through interlibrary loan. Both review authors conducted a full text screen of the remaining 234 articles. Articles were included in the final review if they specified criteria used for mental health screening/evaluation and/or letter writing for GAS, focused on TGD adults, were written in English, and were peer-reviewed publications. Any discrepancies were discussed between the two review authors TA and KK and a consensus was reached. A total of 86 articles met full inclusion criteria. Full documentation of all searches can be found in the Supplementary material .

PRISMA flow diagram demonstrating article review process.

In total, 86 articles were included for review. Eleven articles were focused on ethical considerations while the remaining 75 articles focused on the mental health evaluation and process of writing letters of readiness for GAS. Version 8 of the SOC was published in September of 2022 during the review process of this manuscript and is also included as a reference and point of discussion.

Prior to the publication of the standards of care

Fourteen articles were identified in the literature search as published prior to the development of the WPATH SOC version 1 in 1979. Prominent themes included classification, categorization, and diagnosis of TS. Few publications described the components of a mental health evaluation, and inclusion and exclusion criteria, for GAS. Many publications focused exclusively on transgender females, with a paucity of literature examining the experiences of transgender males during this timeframe.

Authors emphasized accurate diagnosis of TS, highlighting elements of the psychosocial history including early life cross-dressing, preference for play with the opposite gender toys and friends, and social estrangement around puberty ( 3 ). One author proposed the term gender dysphoria syndrome, which included the following criteria: a sense of inappropriateness in one’s anatomically congruent sex role, that role reversal would lead to improvement in discomfort, homoerotic interest and heterosexual inhibition, an active desire for surgical intervention, and the patient taking on an active role in exploring their interest in sex reassignment ( 4 ). Many authors attempted to differentiate between the “true transsexual” and other diagnoses, including idiopathic TS; idiopathic, essential, or obligatory homosexuality; neuroticism; TV; schizophrenia; and intersex individuals ( 5 , 6 ).

Money argued that the selection criteria for patients requesting GAS include a psychiatric evaluation to obtain collateral information to confirm the accuracy of the interview, work with the family to foster support of the individual, and proper management of any psychiatric comorbidities ( 5 ). Authors began to assemble a list of possible exclusion criteria for receiving GAS such as psychosis, unstable mental health, ambivalence, and secondary gain (e.g., getting out of the military), lack of triggering major life events or crises, lack of sufficient distress in therapy, presence of marital bonds (given the illegality of same-sex marriage during this period), and if natal genitals were used for pleasure ( 3 – 5 , 7 – 13 ).

Others focused the role of the psychiatric evaluation on the social lives and roles of the patient. They believed the evaluation should include exploring the patient’s motivation for change for at least 6–12 months ( 8 ), facilitating realistic expectations of treatment, managing family issues, providing support during social transition and post-operatively ( 13 ), and encouraging GAH and the “real-life test” (RLT). The RLT is a period in which a person must fully live in their affirmed gender identity, “testing” if it is right for them. In 1970, Green recommended that a primary goal of treatment was that, “the male patient must be able to pass in society as a socially acceptable woman in appearance and to conduct the normal affairs of the day without arousing undue suspicion” ( 14 ). Benjamin also noted concern that “too masculine” features may be a contraindication to surgery so as to not make an “acceptable woman” ( 7 ). Some publications recommended at least 1–2 years of a RLT ( 3 , 7 , 11 , 15 ), while others recommended at least 5 years of RLT prior to considering GAS ( 12 ). Emphasis was placed on verifying the accuracy of reported information from family or friends to ensure “authentic” motivation for GAS and rule out ambivalence or secondary gain (e.g., getting out of the military) ( 10 ).

Ell recommended evaluation to ensure the patient has “adequate intelligence” to understand realistic expectations of surgery and attempted to highlight the patient’s autonomy in the decision to undergo GAS. He wrote, “That is your decision [to undergo surgery]. It’s up to you to prove that you are a suitable candidate for surgery. It’s not for me to offer it to you. If you decide to go ahead with your plans to pass in the opposite gender role, you do it on your own responsibility” ( 8 ). Notably, many authors conceptualized gender transition along a binary, with individuals transitioning from one end to the other.

In these earliest publications, one can start to see the beginning framework of modern-day requirements for accessing GAS, including ensuring an accurate diagnosis of gender incongruence; ruling out other possible causes of presentation such as psychosis; ensuring general mental stability; making sure that the patient has undergone at least some time of living in their affirmed gender; and that they are able to understand the consequences of the procedure.

Standards of care version 1 and 2

Changes to the standards of care.

The first two versions of the WPATH SOC were written in 1979 and 1980, respectively and are substantially similar to one another. SOC version three was the first to be published in an academic journal in 1985 and changes from the first two versions were documented within this publication. The first two versions required that all recommendations for GAC be completed by licensed psychologists or psychiatrists. The first version recommended that patients requesting GAH and non-genital GAS, spend 3 and 6 months, respectively, living full time in their affirmed gender. These recommendations were rescinded in subsequent versions ( 16 ). Figure 2 reviews changes to the recommendations for GAC within the WPATH SOC over time.

Changes to the World Professional Association for Transgender Health (WPATH) standards of care around gender affirming medical and surgical treatments over time.

Results review

Five articles published between 1979 and 1980 were included in this review. Again, emphasis was placed on proper diagnosis, classification and consistency of gender identity over time ( 17 , 18 ).

Wise and Meyer explored the concept of a continuum between TV and TS, describing that those who experienced gender dysphoria often requested GAS, displayed evidence of strong cross-dressing desires with arousal, history of cross-gender roles, and absence of manic-depressive or psychotic illnesses ( 19 ). Requirements for GAS at the Johns Hopkins Gender Clinic included at least 2 years of cross-dressing, working in the opposite gender role, and undergoing treatment with GAH and psychotherapy ( 19 ). Bernstein identified factors correlated with negative GAS outcomes including presence of psychosis, drug abuse, frequent suicide attempts, criminality, unstable relationships, and low intelligence level ( 18 ). Lothstein stressed the importance of correct diagnosis, “since life stressors may lead some transvestites to clinically present as transsexuals desiring SRS” ( 20 ). Levine reviewed the diagnostic process employed by Case Western Reserve University Gender Identity Clinic which involved initial interview by a social worker to collect psychometric testing, followed by two independent psychiatric interviews to obtain the developmental gender history, understand treatment goals, and evaluate for underlying co-morbid mental health diagnoses, with a final multidisciplinary conference to integrate the various evaluations and develop a treatment plan ( 21 ).

Standards of care version 3

Version 3 broadened the definition of the clinician thereby broadening the scope of providers who could write recommendation letters for GAC. Whereas prior SOC required letters from licensed psychologists or psychiatrists, version 3 allowed initial evaluations from providers with at least a Master’s degree in behavioral science, and when required, a second evaluation from any licensed provider with at least a doctoral degree. Version 3 recommended that all evaluators demonstrate competence in “gender identity matters” and must know the patient, “in a psychotherapeutic relationship,” for at least 6 months ( 16 ). Version 3 relied on the definition of TS in DSM-III, which specified the sense of discomfort with one’s anatomic sex be “continuous (not limited to a period of stress) for at least 2 years” and be independently verified by a source other than the patient through collateral or through a longitudinal relationship with the mental health provider ( 16 ). Recommendation of GAS specifically required at least 6–12 months of RLT, for non-genital and genital GAS, respectively ( 16 ).”

Nine articles were published during the timeframe that the SOC version 3 were active (1981–1990). Themes in these publications included increasing focus on selection criteria for GAS and emphasis on the RLT, which was used to ensure proper diagnosis of gender dysphoria. Recommendations for the duration of the RLT ranged anywhere between 1 and 3 years ( 22 , 23 ).

Proposed components of the mental health evaluation for GAS included a detailed assessment of the duration, intensity, and stability of the gender dysphoria, identification of underlying psychiatric diagnoses and suicidal ideation, a mental status examination to rule out psychosis, and an assessment of intelligence (e.g., IQ) to comment on the individual’s “capacity and competence” to consent to GAC. The Minnesota Multiphasic Personality Inventory (MMPI), Weschler Adult Intelligence Scale (WAIS), and Lindgren-Pauly Body Image Scale were also used during assessments ( 24 ).

Authors developed more specific inclusion and exclusion criteria for undergoing GAS with inclusion criteria including age 21 or older, not legally married, no pending litigation, evidence of gender dysphoria, completion of 1 year of psychotherapy, between 1 and 2 years RLT with ability to “pass convincingly” and “perform successfully” in the opposite gender role, at least 6 months on GAH (if medically tolerable), reasonably stable mental health (including absence of psychosis, depression, alcoholism and intellectual disability), good financial standing with psychotherapy fees ( 25 ), and a prediction that GAS would improve personal and social functioning ( 26 – 29 ). A 1987 survey of European psychiatrists identified their most common requirements as completion of a RLT of 1–2 years, psychiatric observation, mental stability, no psychosis, and 1 year of GAH ( 27 ).

Standards of care version 4

World Professional Association for Transgender Health SOC version four was published in 1990. Between version three and version four, DSM-III-R was published in 1987. Version four relied on the DSM-III-R diagnostic criteria for TS as opposed to the DSM-III criteria in version three. The DSM-III-R criteria for TS included a “persistent discomfort and sense of inappropriateness about one’s assigned sex,” “persistent preoccupation for at least 2 years with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex,” and that the individual had reached puberty ( 30 ). Notable changes from the DSM-III criteria include specifying a time duration for the discomfort (2 years) and designating that individuals must have reached puberty.

Six articles were published between 1990 and 1998 while version four was active. Earlier trends continued including emphasizing proper diagnosis of gender dysphoria ( 31 , 32 ), however, a new trend emerged toward implementing more comprehensive evaluations, with an emphasis on decision making, a key element of informed consent.

Bockting and Coleman, in a move representative of other publications of this era, advocated for a more comprehensive approach to the mental health evaluation and treatment of gender dysphoria. Their treatment model was comprised of five main components: a mental health assessment consisting of psychological testing and clinical interviews with the individual, couple, and/or family; a physical examination; management of comorbid disorders with pharmacotherapy and/or psychotherapy; facilitation of identity formation and sexual identity management through individual and group therapy; and aftercare consisting of individual, couple, and/or family therapy with the option of a gender identity consolidation support group. Psychoeducation was a main thread throughout the treatment model and a variety of treatment “subtasks” such as understanding decision making, sexual functioning and sexual identity exploration, social support, and family of origin intimacy were identified as important. The authors advocated for “a clear separation of gender identity, social sex role, and sexual orientation which allows a wide spectrum of sexual identities and prevents limiting access to GAS to those who conform to a heterosexist paradigm of mental health” ( 33 ).

This process can be compared with the Italian SOC for GAS which recommend a multidisciplinary assessment consisting of a psychosocial evaluation and informed consent discussion around treatment options, procedures, and risks. Requirements included 6 months of psychotherapy prior to initiating GAH, 1 year of a RLT prior to GAS, and provision of a court order approving GAS, which could not be granted any sooner than 2 years after starting the process of gender transition. Follow-up was recommended at 6, 12, and 24 months post-GAS to ensure psychosocial adjustment to the affirmed gender role ( 34 ).

Other authors continued to refine inclusion and exclusion criteria for GAS by surveying the actual practices of health centers. Inclusion criteria included those who had life-long cross gender identification with inability to live in their sex assigned at birth; a 1–2 years RLT (a nearly universal requirement in the survey); and ability to pass “effortlessly and convincingly in society”; completed 1 year of GAH; maintained a stable job; were unmarried or divorced; demonstrated good coping skills and social-emotional stability; had a good support system; and were able to maintain a relationship with a psychotherapist. Exclusion criteria included age under 21 years old, recent death of a parent ( 35 ), unstable gender identity, unstable psychosocial circumstances, unstable psychiatric illness (such as schizophrenia, suicide attempts, substance abuse, intellectual disability, organic brain disorder, AIDS), incompatible marital status, criminal history/activity or physical/medical disability ( 36 ).

The survey indicated some programs were more lenient around considering individuals with bipolar affective disorder, the ability to pass successfully, and issues around family support. Only three clinics used sexual orientation as a factor in decision for GAS, marking a significant change in the literature from prior decades. Overall, the authors found that 74% of the clinics surveyed did not adhere to WPATH SOC, instead adopting more conservative policies ( 36 ).

Standards of care version 5

Published in 1998, version five defined the responsibilities of the mental health professional which included diagnosing the gender disorder, diagnosing and treating co-morbid psychiatric conditions, counseling around GAC, providing psychotherapy, evaluating eligibility and readiness criteria for GAC, and collaborating with medical and surgical colleagues by writing letters of recommendation for GAC ( Figure 3 ). Eligibility and readiness criteria were more explicitly described in this version to refer to the specific objective and subjective criteria, respectively, that the patient must meet before proceeding to the next step of their gender transition. The seven elements to include in a letter of readiness were more explicitly listed within this version as well including: the patient’s identifying characteristics, gender, sexual orientation, any other psychological diagnoses, duration and nature of the treatment with the letter writer, whether the author is part of a gender team, whether eligibility criteria have been met, the patient’s ability to follow the SOC and an offer of collaboration. Version five removes the requirement that patients undertake psychotherapy to be eligible for GAC ( 37 ).

Changes to the ten tasks of the mental health provider within the World Professional Association for Transgender Health (WPATH) standards of care over time.

Five articles were published between 1998 and 2001 while version five was active. Two of these articles were summaries of the SOC ( 37 , 38 ). Themes in these publications included continued attempts to develop comprehensive treatment models for GAS.

Ma reviewed the role of the social worker in a multidisciplinary gender clinic in Hong Kong. Psychosocial assessment for GAS included evaluation of performance in affirmed social roles, adaptation to the affirmed gender role during the 1-year RLT and understanding the patient’s identified gender role and the response to the new gender role culturally and interpersonally within the individual’s support network and family unit. She noted five contraindications to GAS: a history of psychosis, sociopathy, severe depression, organic brain dysfunction or “defective intelligence,” success in parental or marital roles, “successful functioning in heterosexual intercourse,” ability to function in the pretransition gender role, and homosexual or TV history with genital pleasure. She proposed a social work practice model for patients who apply for GAS with categorization of TGD individuals into “better-adjusted” and “poorly-adjusted” with different intervention goals and methods for each. For those who were “better-adjusted,” treatment focused on psychoeducation, building coping tools, and mobilization into a peer counselor role, while treatment goals for those who were “poorly-adjusted” focused on building support and resources ( 39 ).

Damodaran and Kennedy reviewed the assessment and treatment model used by the Monash gender dysphoria clinic in Melbourne, Australia for patients requesting GAS. All referrals for GAS were assessed independently by two psychiatrists to determine proper diagnosis of gender dysphoria, followed by endocrinology and psychology consultation to develop a comprehensive treatment plan. Requirements included RLT of minimum 18 months and GAH ( 40 ).

Miach reviewed the utility of using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), a revision of the MMPI which was standardized using a more heterogeneous population, in a gender clinic to assess stability of psychopathology prior to GAS, which was only performed on patients aged 21–55 years old. The authors concluded that while the TGD group had a significantly lower level of psychopathology than the control group, they believed that the MMPI-2 was a useful test in assessing readiness for GAC ( 41 ).

Standards of care version 6

Published in 2001, version six of the WPATH SOC did not include significant changes to the 10 tasks of the mental health professional ( Figure 3 ) or in the general recommendations for content of the letters of readiness. An important change in the eligibility criteria for GAH allowed providers to prescribe hormones even if patients had not undergone RLT or psychotherapy if it was for harm reduction purposes (i.e., to prevent patient from buying black market hormones). A notable change in version six separated the eligibility and readiness criteria for top (breast augmentation or mastectomy) and bottom (any gender-affirming surgical alteration of genitalia or reproductive organs) surgery allowing some patients, particularly individuals assigned female at birth (AFAB), to receive a mastectomy without having been on GAH or completing a 12 month RLT ( 42 , 43 ).

Thirteen articles were published between 2001 and 2012. One is a systematic review of evidence for factors that are associated with regret and suicide, and predictive factors of a good psychological and social functioning outcome after GAC. De Cuypere and Vercruysse note that less than one percent of patients regret having GAS or commit suicide, making detection of negative predictive factors in a study nearly impossible. They identified a wide array of positive predictive factors including age at time of request, sex of partner, premorbid social or psychiatric functioning, adequacy of social support system, level of satisfaction with secondary sexual characteristics, and surgical outcomes. Many of these predictive factors were later disproved. They also noted that there were not enough studies to determine whether following the WPATH guidelines was a positive predictive factor. In the end they noted that the evidence for all established evaluation regimens (i.e., RLT, age cut-off, psychotherapy, etc.) was at best indeterminate. They recommended that changes to WPATH criteria should redirect focus from gender identity to psychopathology, differential diagnosis, and psychotherapy for severe personality disorders ( 44 ).

The literature at this time supports two opposing approaches to requests for GAC, those advocating for a set of strictly enforced eligibility and readiness criteria associated with very thorough evaluations and those who advocate for a more flexible approach. Common approaches to the evaluation for GAC include: taking a detailed social history including current relationships, support systems, income, and social functioning; a sexual development history meant to understand when and how the patient began to identify as TGD and how their transition has affected their life; an evaluation of their coping skills, “psychic functions” and general mental well-being; and a focus on assessing the “correct diagnosis” of gender identity disorder ( 44 – 56 ). The use of a multidisciplinary team was also commonly recommended ( 44 , 47 , 48 , 51 , 54 – 56 ).

Those that advocated for a stricter interpretation of the eligibility and readiness criteria emphasized the importance of the RLT ( 45 , 49 , 51 , 53 , 55 , 56 ). One clinic in the UK required a RLT lasting 2 years prior to starting GAH, twice as long as recommended by the SOC ( 49 ). The prevailing view continued to approach gender as a binary phenomenon, rather than as a spectrum of experiences. As a result, treatment recommendations emphasized helping the patient to “pass” in their chosen gender role and did not endorse patients receiving less than the full spectrum of treatment to transition fully from one sex to the other. Several authors indicated that they required some amount of psychotherapy before recommending GAC ( 46 , 47 , 51 , 52 , 55 , 56 ). One author described requirements in Turkey, which unlike the US has the requirements enshrined in law and defines an important role for the courts in granting permission for GAC ( 51 ). In general, these authors supported the gatekeeping role of the mental health provider as a mechanism to prevent cases of regret.

Among groups supporting a flexible interpretation of the SOC, there was a much stronger emphasis on the supportive role of the mental health provider in the gender transition process ( 44 – 46 , 48 , 52 , 53 ). This role included creating a supportive environment for the patient, asking and using the correct pronouns, and helping to guide them through what may be a difficult transition both socially and physically. They emphasized the importance of the psychosocial evaluation including the patient’s connections to others in the TGD community, their social functioning, substance use, and psychiatric history/psychological functioning. While informed consent was mentioned as part of the evaluation, the process was not thoroughly explored and largely focused on patients’ awareness that GAS is an irreversible procedure which removes healthy tissue ( 53 ). One author suggested that a “consumer handbook outlining such rights and responsibilities” related to GAS be made available, but they made no further comment on the informed consent process ( 44 ). There was no further guidance as to the contents of letters of readiness for GAC.

The lack of emphasis on informed consent by both groups of authors mirrors the discussion of informed consent within the SOC, which up through version six, had a relatively narrow definition and role specifically related to risks and benefits of surgery. As far back as version one, the SOC states “hormonal and surgical sex reassignment are procedures which must be requested by, and performed only with the agreement of, the patient having informed consent…[these procedures] may be conducted or administered only after the patient applicant has received full and complete explanations, preferably in writing, in words understood by the patient applicant, of all risks inherent in the requested procedures ( 16 ). “This reflects the dominant concerns of surgeons at the time that they were removing or damaging healthy tissue, which was unethical, and as such wanted to make sure that patients understood the irreversibility of the procedures. It was not until version 7 that there is a change in the discussion of informed consent.

Standards of care version 7

Standards of care version seven was published in 2013. Publication of version seven coincided with the publication of DSM-5, in which the diagnosis required to receive GAC shifted from Gender Identity Disorder to Gender Dysphoria, in an effort to de-pathologize TGD patients. Version seven highlights that these are guidelines meant to be flexible to account for different practices in different places. Compared to version six, a significantly expanded section on the “Tasks of the Mental Health Provider” was added, offering some instructions on what to include in the assessment of the patient for GAS. For the first time the SOC expand on what it means to obtain informed consent and describe a process where the mental health provider is expected to guide a conversation around gender identity and how different treatments and procedures might affect TGD individuals psychologically, socially, and physically. Other recommendations include “at a minimum, assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender non-conformity on mental health, and the availability of support from family, friends, and peers.” There is also a change to the recommended content of the letters: switching from “The initial and evolving gender, sexual, and other psychiatric diagnoses” to “Results of the client’s psychosocial assessment, including any diagnoses”, indicating a shift in the focus away from diagnosis toward the psychosocial assessment. Version 7 also adds two new tasks for the mental health provider including “Educate and advocate on behalf of clients within their community (schools, workplaces, other organizations) and assist clients with making changes in identity documents” and “Provide information and referral for peer support”( 2 ).

There were also significant changes to eligibility criteria for GAC. For GAH, version seven eliminates entirely the requirement for a RLT and psychotherapy and adds requirements for “persistent well documented gender dysphoria” and “reasonably well controlled” medical or mental health concerns. Notably, the SOC do not define the meaning of “reasonably well controlled,” leaving providers to interpret this on their own. Version seven delineates separate requirements for top and bottom surgeries. The criteria for both feminizing and masculinizing top surgeries are identical to each other and identical to those laid out for GAH. Version seven explicitly states that GAH is not required prior to top surgery, although GAH is still recommended prior to gender-affirming breast augmentation. Criteria for bottom surgery are more explicitly defined, namely internal (i.e., hysterectomy, orchiectomy) vs. external (i.e., metoidioplasty, phalloplasty, and vaginoplasty). For internal surgeries, criteria are the same as for top surgery with the addition of a required 12 months of GAH. For external surgeries the criteria are the same as for internal, with the addition of required 12 months of living in the patient’s affirmed gender identity ( 2 , 42 ).

Twenty-three articles were published while version 7 of the SOC have been active. Themes include identifying the role of psychometric testing in GAC evaluations, expanding the discussion around informed consent for GAC, and revising the requirements for letter writers.

A systematic review evaluated the accuracy of psychometric tests in those requesting GAC, identifying only two published manuscripts that met their inclusion criteria, both of which were of poor quality; this led them to question the utility of psychometric tests in in TGD patients ( 57 ). Keo-Meir and Fitzgerald provided a detailed narrative review of psychometric and neurocognitive exams in the TGD population and concluded that psychometric testing should not be done unless there is a question about the capacity of the patient to provide informed consent ( 58 ). The only other manuscripts that include a mention of psychological testing describe processes in Iran and China, both of which require extensive psychological testing prior to approval for GAC ( 59 , 60 ). These two manuscripts, in addition to an ethnographic study of the evaluation process in Turkey ( 61 ), are also the only ones that indicate a requirement for psychotherapy prior to approval for treatment. The three international manuscripts described above plus three manuscripts from the US ( 62 – 64 ) are the only ones to include consideration of a RLT, with authors outside the US preferring a long RLT and US authors considering RLT as part of the informed consent process for GAS, and not required at all prior to the initiation of GAH.

Many authors describe the process of informed consent for GAC ( 1 , 58 , 60 , 62 – 76 ). In China, a signature indicating informed consent from the patient’s family is required in addition to that of the patient ( 60 ). Many authors emphasize evaluating for and addressing social determinants of health including housing status, income, transportation, trauma history, etc. ( 1 , 58 , 60 , 67 , 69 – 71 , 75 – 77 ). Deutsch advocated for the psychosocial evaluation being the most important aspect of the evaluation and suggests that one of the letters required for bottom surgery be replaced by a functional assessment (i.e., ADLs/iADLs), which could be repeated as needed or removed entirely for high functioning patients ( 69 ).

Practice patterns and opinions on who should write letters of readiness and how many letters should be required vary widely. Many letters that surgeons receive are cursory, and short and non-personal letters correlate with poor surgical outcomes ( 1 ). Several authors advocate for eliminating the second letter entirely, for at least some procedures, as it is a barrier to care ( 68 , 69 , 74 ). Some support removing the requirement that both letter writers be therapists or psychiatrists, and even suggesting the second letter be written by a urologist ( 72 ) or a social worker who has performed a detailed social assessment ( 69 , 75 ). The evaluation in Turkey requires a report written by an extensive multidisciplinary team and submitted to a court for approval ( 61 ). Surveys of providers indicate that the SOC are not uniformly implemented leading to huge disparities based on the providers knowledge level and personal beliefs ( 77 , 78 ). Additional recommendations include that providers spend significant time discussing the SOC and diagnosis of gender dysphoria with the patients prior to providing a letter to prepare them for the stigma such a diagnosis may confer ( 65 , 66 ), and dropping gender dysphoria entirely in favor the ICD-11 diagnosis of gender incongruence, as it may be less stigmatizing ( 71 ).

The Mount Sinai Gender Clinic describes an integrated multidisciplinary model where a patient will see a primary care doctor, endocrinologist, social worker, psychiatrist, and obtain any necessary lab work in a single visit, significantly reducing barriers to care. The criteria in this model focus on informed consent, the social determinants of health, being physically ready for surgery, and putting measurable goals on psychiatric stability, while deemphasizing the gender dysphoria diagnosis. Their study showed that people who received their evaluation over a 2-year period were more likely to meet their in-house criteria than they were to meet criteria as set forth in WPATH SOC. The Mount Sinai criteria allowed for significantly decreased barriers to care, allowing more people to progress through desired GAC in a timely fashion ( 75 ).

Standards of care version 8

Standards of care version 8, published in September 2022, includes major updates to the guidelines around GAS. This version explicitly highlights the importance of informed decision making, patient autonomy, and harm reduction models of care, as well as emphasizing the flexibility of the guidelines which the authors note can be modified by the healthcare provider in consultation with the TGD individual.

Version 8 lays out the roles of the assessor which are to identify the presence of gender incongruence and any co-existing mental health concerns, provide information on GAC, support the TGD individual in their decision-making, and to assess for capacity to consent to GAC. The authors emphasize the collaborative nature of this decision-making process between the assessor and the TGD individual, as well as recommending TGD care occur in a multidisciplinary team model when possible.

Version 8 recommends that providers who assess TGD individuals for GAC hold at least a Master’s level degree and have sufficient knowledge in diagnosing gender incongruence and distinguishing it from other diagnoses which may present similarly. These changes allow for non-mental health providers to be the main assessors for GAC.

Version 8 recommends reducing the number of evaluations prior to GAS to a single evaluation in an effort to reduce barriers to care for the TGD population. Notably, the authors have removed the recommendations around content of the letter of readiness for GAC. The guidelines note that the complexity of the assessment process may differ from patient to patient, based on the type of GAC requested and the specific characteristics of the patient. Version eight directly states that psychometric testing and psychotherapy are not requirements to pursue GAC. While evaluations should continue to identify co-existing mental health diagnoses, version 8 highlights that the presence of a mental health diagnosis should not prevent access to GAC unless the mental health symptoms directly interfere with capacity to provide informed consent for treatment or interfere with receiving treatment. Version 8 recommends that perioperative matters, such as travel requirements, presence of stable, safe housing, hygiene/healthy living, any activity restrictions, and aftercare optimization, be discussed by the surgeon prior to GAS. In terms of eligibility criteria, the authors recommend a reduced duration of GAH from 12 months (from version 7) to 6 months (in version 8) prior to pursuing GAS involving reproductive organs ( 79 ).

Ethical discussions

A total of eleven articles explored ethical considerations of conducting mental health evaluations and writing letters of readiness for GAS, including a comparison of the ethical principles prioritized within the “gatekeeping” model vs. the informed consent model for GAC and the differential treatment of TGD individuals compared to cisgender individuals seeking similar surgical procedures.

Many authors compare the informed consent model of care for TGD individuals to the WPATH SOC model. In the informed consent model, the role of the health practitioner is to provide TGD patients with information about risks, side effects, benefits, and possible consequences of undergoing GAC, and to obtain informed consent from the patient ( 80 ). Cavanaugh et al. argue that the informed consent model is more patient-centered and elevates the ethical principle of autonomy above non-maleficence, the principle often prioritized in the “gatekeeping” model ( 81 ). They write, “Through a discussion of risks and benefits of possible treatment options with the patient…clinicians work to assist patients in making decisions. This approach recognizes that patients are the only ones who are best positioned, in the context of their lived experience, to assess and judge beneficence (i.e., the potential improvement in their welfare that might be achieved), and it also affords prescribing clinicians a better and fuller sense of how a particular patient balances principles of non-maleficence and beneficence.” Authors note that mental health providers can be particularly helpful in situations where an individual desires additional mental health treatment, which some argue should remain optional, or when an individual’s capacity is in question ( 81 ). Additional ethical considerations include balancing the respect for the dignity of persons, responsible caring, integrity in relationships, and responsibility to society ( 82 ). Other authors argue for a more systematic approach to ethical issues, including consulting the literature and/or experts in the field of TGD mental health for support in making decisions around GAC ( 74 ).

Hale criticizes the WPATH SOC noting that these guidelines create a barrier between patient and mental health provider in establishing trust and a therapeutic relationship, overly pathologize TGD individuals, and unnecessarily impose financial costs to the TGD individual. As a “gatekeeper,” the mental health provider is placed in the position of either granting or denying GAC and must weigh the competing ethical principles of beneficence, non-maleficence, and autonomy. He argues that mental health providers are not surrogate decision makers and that framing requests for GAS as a “phenomenon of incapacity” is “reflective of the overall incapacitating effects of society at large toward the TGD community” ( 83 ). This reflects the broader approach to determining capacity utilized in other medical contexts, namely that patients have capacity until proven otherwise ( 84 ). Additionally, due to the gatekeeping dynamic between patient and clinician, many TGD patients may not mention concerns or fears surrounding GAS out of concern they will be denied services, thereby limiting the quality and utility of the informed consent discussion. Ashley proposes changes to the informed consent model, specifically that the informed consent process should include not only information about whether to go through with a procedure, but how to go through the procedure including relevant information about timeline, side effects, need for perioperative support, and treatment plan ( 85 ). Gruenweld argues for a bottom-up, TGD-led provision of GAC instead of focusing solely on alleviating gender dysphoria through a top-down, medical expert approach via such systems like the WPATH SOC ( 86 ).

MacKinnon et al. conducted an institutional ethnographic study of both TGD individuals undergoing mental health evaluations for GAC and mental health providers to better understand the process of conducting such evaluations ( 87 ). They found that providers cited three concerns with the evaluation: determining the authenticity of an individual’s TGD identity, determining if the individual has the capacity to consent to treatment, and determining the readiness of the individual to undergo treatment. TGD individuals cited concerns around presenting enough distress to be diagnosed with gender dysphoria (a SOC requirement) versus too much distress, and risk being diagnosed with an uncontrolled mental health condition therefore being ineligible for GAC. The authors conclude, “although they are designed to optimize and universalize care… psychosocial readiness assessments actually create a medically risky and arguably unethical situation in which trans people experiencing mental health issues have to decide what is more important – transitioning at the potential expense of care for their mental health or disclosing significant mental health issues at the expense of being rendered not ready to transition (which in turn may produce or exacerbate mental distress)” ( 87 ).

With regards to writing letters of readiness for GAS, authors comment on the differential treatment of TGD compared to cisgender individuals. Bouman argues that requiring two letters for gender-affirming orchiectomy or hysterectomy is unethical given that orchiectomy and hysterectomy for chronic scrotal pain and dysfunctional uterine bleeding, respectively, do not require any mental health evaluation. Requiring a second letter may cause delays in treatment, increase financial costs, and may be invasive to the patient who must undergo two detailed evaluations, while allowing for diffusion of responsibility for the mental health provider ( 88 ).

Changing standards

Starting in the 1950’s with the first successful gender affirming procedure in the US on Christine Jorgenson, TGD people in the US started seeking surgical treatment of what was then called TS. The medical community’s understanding of TGD people, their mental health, and the role of the mental health provider in their medical and surgical transition has progressed and evolved since this time. Prior to the first iteration of what would later be known as WPATH’s SOC, patients were mostly evaluated within a system that viewed gender and sexual minorities as deviants and thereby largely limited access to GAC. We can also see this reflected in the changes to DSM and ICD diagnostic criteria between 1980 and today which demonstrates a trend from pathologizing identity and conflating sexual and gender identity toward pathologizing the distress experienced due to the discordant identity, and finally removing the relevant diagnosis from the chapter of Mental and Behavioral Disorders altogether in the ICD and instead into a new chapter titled “conditions related to sexual health ( 89 ).” These changes have clearly yielded positive benefits for TGD individuals by reducing stigma and improving access to care, but significant problems remain. Requiring TGD people to have a diagnosis at all to obtain care, no matter the terminology used, is pathologizing. The practice of requiring a diagnosis continues to put mental health and other medical providers in the position of gatekeeping, continuing the vestigial historical focus on “confirming” a person’s gender identity, rather than trusting that TGD people understand their identities better than providers do. Version 8 of the SOC put a much heavier emphasis on shared decision making and informed consent, but continue to maintain the requirement of a diagnosis ( 79 ). Many insurance companies and other health care payers require the diagnosis to justify paying for GAC, but providers should continue to advocate for removing such labels as a gatekeeping mechanism for GAC.

With each version of the SOC, guidelines for GAC become more specific, with more explanation of the reasoning behind each recommendation; more flexible requirements, a broadening of the definition of mental health provider, and elimination of the requirement that at least one letter be written by a doctoral level provider. There has been a notable shift in the conceptualization of gender identity, away from a strict gender binary, with individuals transitioning fully from one end to the other, to gender identity and transition as a spectrum of experiences. Over time the SOC became more flexible by removing requirements for psychotherapy, narrowing requirement for the RLT to only those pursuing bottom surgery, eliminating requirements for a mental health evaluation prior to initiating GAH, and eliminating requirements for GAH prior to top surgery. Version 8 of the SOC was even more explicit about removing requirements for psychotherapy and psychometric testing prior to receiving GAC ( 79 ).

Despite these positive changes, those wishing to access GAC still face significant challenges. Access to providers knowledgeable about GAC remains limited, especially in more rural areas, therefore requiring evaluations and letters of readiness for GAC continues to significantly limit access to treatment. By requiring letters of readiness for GAC, adult TGD individuals are not afforded the same level of autonomy present in almost any other medical context, where capacity to provide informed consent is automatically established ( 84 ). The WPATH SOC continue to perpetuate differential treatment of TGD individuals by requiring extensive, and often invasive, evaluations for procedures that their cisgender peers are able to access without such evaluations ( 88 ). The WPATH guidelines apply a one-size-fits-all approach to an extremely heterogeneous community who have varying levels of needs based on a variety of factors including but not limited to age, socioeconomic status, race, natal sex, and geographic location ( 90 ). It should be noted, however, that the version 8 of the SOC does acknowledge that different patients may require evaluations of varying complexity based on the procedure they are requesting as well as a variety of psychosocial factors, although it remains vague about exactly what those different evaluations should entail ( 79 ). We propose that future work be directed toward three primary goals: conducting research to determine the utility of letters of readiness; to better understand factors that impact GAS outcomes; and to develop easily accessible and understandable guides to conducting readiness evaluations and writing letters. These aims will help to further our goals of advocating for this vastly underserved population by further removing barriers to life-saving GAC.

Changing ethics

Early iterations of the SOC were strict, placing the mental health provider within a gatekeeper role, tasked with distinguishing the “true transsexual” that would benefit from GAS from those who would not, which in effect elevated the ethical principal of non-maleficence above autonomy. This created a barrier to forming a therapeutic alliance between the patient and mental health provider as there was little motivation for patients to give any information outside of the expected gender narrative ( 50 , 65 ). Mistrust flowed both ways leading to longer and more involved evaluations then than what is required today, with many providers requiring patients to undergo extensive psychological testing and psychotherapy, provide extensive collateral, and undergo lengthy RLTs, with some focusing on a patient’s ability to “pass” within the desire gender role, before agreeing to write a letter ( 11 , 15 , 19 , 49 , 57 , 58 ).

As understanding around the experiences of TGD individuals has evolved over time, the emphasis has shifted from the reliance on non-maleficence toward elevating patient autonomy as the guiding principle of care. Evaluations within this informed consent model focus much more on the patient’s ability to understand the treatment, its aftercare, and its potential effect on their lives. Informed consent evaluations also shift focus toward other psychosocial factors that will contribute to successful surgical outcomes, for example, housing, transportation, a support system, and treatment of any underlying mental health symptoms. While there is still a lack of consistency in current evaluations and the SOC are enforced unevenly ( 77 ), the use of the informed consent model by some providers has reduced barriers for some patients. Many authors now agree that psychological or neuropsychological testing should not be used when evaluating for surgical readiness unless there is a concern about the patient’s ability to provide informed consent such as in the case of a neurocognitive or developmental disorder ( 58 ). Also important to note here is that while there is a general shift in the focus of the literature from that of gatekeeping toward one of informed consent, neither the informed consent model nor the WPATH SOC more broadly are evenly applied by providers, leading to continued barriers for many patients ( 77 , 78 ).

Within the literature, there is support for further reducing barriers to care by widening the definition of who can conduct evaluations, write letters, or facilitate the informed consent discussion for GAC. Recommending that the physician providing the GAC be the one to conduct the informed consent evaluation would bring GAC practices more in line with practices in place within the broader medical community. It is very rare for mental health providers to be the gatekeepers for medical or surgical procedures, except for transplant surgery, where mental health providers may have a clearer role given the prominence of substance use disorders and the very limited resource of organs. However, even within transplant psychiatry, a negative psychiatric evaluation would not necessarily preclude the patient from receiving the transplant, but instead may be used to guide a treatment plan to improve chances of a successful recovery post-operatively. We then should consider what it means to embrace patient autonomy as our guiding principle, especially with more than 40 years of evidence of the positive effects around GAC behind us. Future guidelines should focus on making sure that TGD individuals are good surgical candidates, not based on their gender identity, but instead on a more holistic understanding of the factors that lead to good and bad gender-affirming surgical outcomes, along the lines of those proposed by Mt. Sinai’s gender clinic for vaginoplasty ( 75 ). Additionally, the physicians providing the GAC should in most cases be the ones to obtain informed consent, while retaining the ability to request a mental health evaluation if specific concerns related to mental health arise. This would both allow mental health providers to adopt a supportive consultant role rather than that of gatekeeper, as well as provide more individualized rather than one-size-fits-all care to patients.

Version 8 of the SOC go a long way toward changing the ethical focus of evaluations toward one of shared decision making and informed consent by removing the requirement of a second letter and the requirement that the letter be written by a mental health provider. This will, in theory, lower barriers to care by allowing other providers (as long as they have at least a master’s degree) to write letters for surgery ( 79 ). In practice, however, this change is likely to only affect a small portion of the patient population. This is because, as noted in the section below in more detail, insurance companies already do not adhere closely to the SOC ( 91 ) and are unlikely to quickly adopt the new guidelines if at all. Further, it is possible that many surgeons will require that the letter of readiness be written by a mental health provider, especially if the patient has any previous mental health problems. While changes to SOC 8 are a step in the direction we propose in this manuscript, it is important to remember that the primary decision makers of who can access GAC in the US are insurance companies with surgeons, primary care providers, and mental health providers as secondary decision makers; this leaves patients with much less real-world autonomy than the SOC state they should have in the process. While insurance companies hold this effective decision-making power in all of US healthcare, it could be at least partially addressed by developing clear, evidence based guidelines for which patients might require a more in-depth evaluation in the first place. Screening out patients that have little or no mental health or social barriers to care would directly reduce those patients’ barriers to receiving GAC, while freeing up mental health and other providers to provide evaluation, resources, and support to those patients who will actually benefit from these services.

Letter writing

There are few published guides for writing letters of readiness for GAC. The WPATH SOC provide vague guidelines as to the information to include within the letter itself, which, in addition to a lack of consistency in implementation of the SOC, lead to a huge variety in current practices around letter writing and limit their usefulness to surgical providers ( 1 ). There is much debate within the literature about how many letters should be required and who should be able to write them. Guidelines from China, Turkey, and Iran recommend much stricter processes requiring input from a wider variety of specialists to comment on a patient’s readiness ( 59 – 61 ). Within the US, the few recent recommendations include having a frank discussion with patients about the gender dysphoria diagnosis and allowing them to have input into the content of the letter itself ( 65 , 66 , 70 , 71 , 75 ). The heterogeneity of current practices around letter writing demonstrates a reality in which many providers do not uniformly operate within the informed consent model, and do not even uniformly adhere to the SOC as written. This heterogeneity in practice by providers also extends to requirements by insurance companies in the US. The lack of clear guidelines about what should go into a letter, especially across different insurance providers, can lead to increased barriers to care due to insurance denials for incorrectly written letters. While direct data examining insurance denials for incorrectly written letters is not available, we can see this indirect effects in the fact that while 90% of insurance providers in the US provide coverage for GAC, only 5–10% of TGD patients had received bottom surgery even though about 50% of TGD patients have reported wanting it ( 91 ). Version 8 of the SOC reduce some of the letter writing requirements as discussed above, but they still do not give clear instructions on exactly how to write a letter of readiness or perform an evaluation ( 79 ). Given the lack of uniformity and limited benefit of such letters to surgical providers, these authors propose that future research be conducted into the need for letters of readiness for GAC, ways to ensure the content of such letters are evidence-based to improve outcomes of GAC, and improve education to providers by creating an easily accessible and free semi-structured interview with letter template.

Limitations

The reviewed articles included opinion manuscripts, published SOC, and proposed models for how to design and operate GAC clinics, however, this narrative review is limited by a lack of peer reviewed clinical trials that assess the evidence for the GAC practices described here. As a result, it is challenging to comment on the effectiveness of various interventions over time.

The WPATH SOC have evolved significantly over time with regards to their treatment of TGD individuals. Review of the literature shows a clear progression of practices from paternalistic gatekeeping toward increasing emphasis on patient autonomy and informed consent. Mental health evaluations, still required by SOC version eight are almost entirely unique as a requirement for GAS, apart from some bariatric and transplant surgeries. Individuals who wish to pursue GAC are required to get approval for treatments that their cisgender peers may pursue without such evaluations. While there may be some benefits from these evaluations in helping to optimize a patient socially, emotionally, and psychologically for GAC, the increased stigma and burden placed on patients by having a blanket requirement for such evaluations leads us to seriously question the readiness evaluation requirements in SOC version 8, despite a reduction in the requirements compared to previous SOC. This burden is made worse by limited access to providers knowledgeable and competent in conducting GAC evaluations, writing letters of readiness, and a lack of consistency in the application and interpretations of the SOC by both providers and insurance companies. Other barriers to care created by multiple letter requirements include the often-prohibitive cost of getting multiple evaluations and the delay in receiving their medical or surgical treatments due to extensive wait times to see a mental health provider. This barrier will in theory be ameliorated by updates to SOC in version 8, but multiple letters are likely to at least be required by insurance companies for some time. Overall, the shift from gate keeping to informed consent has been a net positive for patients by reducing barriers to care and improving patient autonomy, but the mental health evaluation is still an unnecessary barrier for many people. Further research is necessary to develop a standardized evaluation and letter template for providers to access, as well as further study into who can most benefit from an evaluation in the first place.

Data availability statement

Author contributions.

TA and KK contributed to the conception and design of the study under the guidance of RL and AJ, reviewed and analyzed the literature, and wrote the manuscript. AW organized the literature search and wrote the “Methods” section. RL and AJ assisted in review and revision of the completed manuscript. All authors approved of the submitted version.

Abbreviations

1 Gender affirming surgery has historically been referred to as sexual reassignment surgery (SRS).

2 Gender affirming care is an umbrella term referring to any medical care a TGD individual might pursue that affirms their gender identity, including primary care, mental health care, GAH or GAS.

3 The organization will be referred to as WPATH moving forward, even when referring to time periods before the name change.

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.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.1006024/full#supplementary-material

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For Singapore's LGBTQ Community, Legal and Procedural Hurdles Linger

When 21-year-old Alexander Teh flew from Singapore to Bangkok with his parents earlier this month, he expected to have the first of his female-to-male gender reassignment surgeries: a scheduled bilateral mastectomy. Instead, his surgeon sent him to see a psychiatrist at a nearby hospital. “He said he was sending me to see a psychiatrist for my parents, to ease them into the process,” Teh explained.

The meeting went well at first, until the psychiatrist asked Teh whether he was attracted to men or women. “I said I was attracted to guys, and she said ‘Interesting,’ so I thought it wasn’t an issue,” Teh said. But at the end of the meeting Teh was told he’d have to go through another series of psychological tests before he would be allowed to have the surgery.

“The psychiatrist said it was quite clear that I had gender dysphoria, but she was confused as to why I would choose to like guys and not girls,” Teh said. “I told her, I didn’t choose it, it’s just the way it is.”

The psychiatrist told Teh he would still need to take further tests, and scheduled the tests for a date after Teh and his parents had planned to leave Bangkok. Teh ended up returning to Singapore without having the surgery.

For many transgender men and women like Teh, living in Singapore and navigating the process of transitioning can often involve a series of legal and procedural hurdles that can create challenges beyond simply fighting for social acceptance from family, friends, and colleagues.

RELATED: Vietnam's LGBTQ Movement Is in Full Bloom

In Singapore, a person cannot have one’s gender marker legally changed on official documents without first undergoing gender reassignment surgery and sterilization . This is a much stricter policy when compared to countries like Argentina or Denmark , which require no surgery or any type of medical verification to have a person’s preferred gender legally recognized by the government.

“Personally, I can see why it’s a requirement,” Teh said of Singapore’s policy. “But for trans people who don’t have the means for these surgeries, whether for financial or health reasons, [the requirement] hinders the quality of life for these people. Because them having these reproductive organs doesn’t make them any less of the person that they identify as.” He also noted some people simply don’t feel the need to undergo surgery as part of their transition.

For Teh, it was a step he wanted to take, and he decided to travel to Bangkok for his surgery because the specific procedure he wanted wasn’t performed in Singapore. He didn’t expect that his identification as a gay man to the psychiatrist would have created a hurdle so early on in the process, preventing him from having the surgery as originally planned.

If anything, Teh had prepared himself for the legal hurdles being a gay man might cause after his gender marker was legally changed to male, since the act of sex between two men is still criminalized in Singapore and punishable with up to two years in prison, as stated in Section 377A of the Penal Code .

“It’s not actively enforced,” Teh said of the law. “But it is a concern that this law could be used against people, not just myself but other people in Singapore as well, because it’s there.”

RELATED: LGBTQ Activists in Brazil Use Social Media to Spread Awareness, Acceptance

Roy Tan has been archiving Singapore’s LGBTQ history for nearly two decades, and says laws like Section 377A can have an outsized effect on the lives of LGBTQ individuals living in Singapore, even if not actively enforced.

“The law has an enormous influence over how the population views homosexuality, since most policies in Singapore are top-down,” Tan explained. “Once you change the law, public opinion regarding homosexuality will change accordingly.”

Tan added Section 377A specifically affects censorship and sex education. “There can be no positive portrayal of LGBTQ people because of censorship policies , and these are backed by the criminalization of gay sex,” Tan explained. “Any mention of gay rights, even by Ellen DeGeneres or President Obama is regarded as promoting homosexuality and has to be censored .”

Sujith Kumar, cofounder of the Purple Alliance, an LGBTQ organization in Singapore, believes Section 377A is one of the biggest barriers to progress for the LGBTQ community in the country. “How do we move forward when all mainstream society hears is that being gay is somehow against the law, against the ‘family’ and against ‘nature’?” he asked.

RELATED: Kenyan Artist Brings Visibility to Nairobi's LGBTQ Community

The constitutionality of Section 377A has been challenged in recent years by two high profile cases brought on by gay men, but both cases failed to result in the law being repealed . According to a report provided to the United Nations by the government of Singapore in October 2015 , the law remains because “segments of Singapore society continue to hold strong views against homosexuality for various reasons including religious convictions and moral values.” Although the report also stressed that “while Section 377A is retained, the Government does not proactively enforce it.”

How much the law will directly affect Teh once his gender marker is legally changed to male is not something he’s entirely clear of, but it’s something he’d rather not have to think about as he deals with the other hurdles of transitioning. “I think that if it’s not being actively enforced then you should just do away with it,” Teh said. “It still creates a hostile environment for gay men in Singapore.”

But this is something Teh will deal with at a later time, since for all legal purposes the government of Singapore still considers Teh to be female. He is still determined to continue the process of his gender reassignment surgeries and hasn’t let the road block caused by his experience with the psychiatrist in Bangkok deter him. If anything, he’s inspired to work harder toward his own goals of working in mental health once he graduates college.

“I hope someday to be qualified enough to specialize in LGBTQ mental health care, so in the future I can provide better help for trans people specifically,” he said. “I think no one should have to suffer to get to where they want to be, so if I could do something to change that then that would be great.”

Follow NBC OUT on Twitter , Facebook and Instagram .

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Follow-up study of female transsexuals

Affiliation.

• 1 Gleneagles Medical Centre, KOK & Tsoi Psychiatric Clinic, Singapore.
• PMID: 8579306

The aim of this study was to examine the social and sexual adjustments of Singapore female transsexuals following sex reassignment surgery. All female transsexuals who were operated on since 1989 were interviewed. There were a total of 17 transsexuals with a mean age of 29 years (range, 20 to 41 years) at the time of inception. Before surgery, all were single. After surgery, 6 out of 11 subjects had married abroad. Before surgery, some had problems with identity cards, passports, travelling and work which were resolved with surgery. They were better accepted and had better sexual adjustment after surgery. All were satisfied with the change in sex, but only 65% were satisfied with the surgery. Only 59% said they were willing to undergo the operation again. After a test case in court, they were unable to marry in Singapore. Their primary motive to undergo sex reassignment surgery was to become a member of the opposite sex, so that they could be recognised socially and legally.

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• Follow-up study of transsexuals after sex-reassignment surgery. Tsoi WF. Tsoi WF. Singapore Med J. 1993 Dec;34(6):515-7. Singapore Med J. 1993. PMID: 8153713
• Male-to-female and female-to-male transsexuals: a comparison. Kockott G, Fahrner EM. Kockott G, et al. Arch Sex Behav. 1988 Dec;17(6):539-46. doi: 10.1007/BF01542341. Arch Sex Behav. 1988. PMID: 3223814
• Outcome of sex reassignment surgery. Lundström B, Pauly I, Wålinder J. Lundström B, et al. Acta Psychiatr Scand. 1984 Oct;70(4):289-94. doi: 10.1111/j.1600-0447.1984.tb01211.x. Acta Psychiatr Scand. 1984. PMID: 6388248 Review.
• A follow-up study of operated transsexual males. Sørensen T. Sørensen T. Acta Psychiatr Scand. 1981 May;63(5):486-503. doi: 10.1111/j.1600-0447.1981.tb00698.x. Acta Psychiatr Scand. 1981. PMID: 7315491
• Psychosocial adjustment in male-to-female transsexuals: an overview of the research evidence. Midence K, Hargreaves I. Midence K, et al. J Psychol. 1997 Nov;131(6):602-14. doi: 10.1080/00223989709603842. J Psychol. 1997. PMID: 9390414 Review.
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Welcome to /r/singapore: The place for anything Singapore.

A transguy and wants to change legal gender on my ID, but not sure how?

Hey, so a friend is a transguy and passes very well, too well in fact. He ends up confusing people because he's very tall and quite manly looking.

He has a female marker on his ID, and he doesn't want to/can't get a hysterectomy due to the risks ( family has risk factors that would lead to complications if he got one, not stating for anonymity). He also lacks funds for phalloplasty or metioplasty and finds getting a job hard due to his mismatch inbetween his IC and physical looks.

This had made getting a job and interacting with people hard, so he wants to change the gender on his IC. After COVID he plans on getting top surgery, and I'm wondering if his Thai surgeron (Dr. Kamol writes him a letter stating he has completed sex reassignment surgery, with the specific terms), he'll be able to get my gender marker changed.

Info online is hella spotty at best and doesn't say what surgery is needed to change your gender, but only a letter is needed from a medical professional.

So yeah, I would love if a fellow transguy or two could give my friend some help here... Its hard to get a job when you're tall and manly but that ID reads F.

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Morrisey takes sex-reassignment surgery ruling to Supreme Court

BRIDGEPORT, W.Va (WDTV) - West Virginia Attorney General Patrick Morrisey is backing the state’s decision not to cover sex-reassignment surgeries under its Medicaid plan and taking the case to the U.S. Supreme Court.

Morrisey made the announcement in a news conference in Bridgeport Thursday following an 8-6 decision from the U.S. Court of Appeals for the Fourth Circuit in April that said the exclusion of the surgery violated the Equal Protection Clause, the Medicaid Act, and the Affordable Care Act’s non-discrimination provision.

Morrisey said states have wide discretion to determine what procedures their programs can cover based on cost and other concerns under Medicaid and that West Virginia should have the ability to determine how to spend their resources to care for the “vital medical needs of their citizens.”

“Just one single sex-reassignment surgery can cost tens of thousands of dollars — taxpayers should not be required to pay for these surgeries under Medicaid,” Morrisey said.

Read a copy of the SCOTUS filing here .

Copyright 2024 WDTV. All rights reserved.

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Sununu signs bills to ban gender-reassignment surgery for minors, organize sports based on student's sex on their birth certificate

Musk says estranged child's gender-affirming care sparked fight against 'woke mind virus'

Tesla CEO Elon Musk said his estranged transgender daughter was "killed" by the "woke mind virus" after he was tricked into agreeing to gender-affirming care procedures .

In an interview with psychologist and conservative commentator Dr. Jordan Peterson , the X owner called gender-reassignment surgery "child mutilation and sterilization." He then discussed his 20-year-old child Vivian Jenna Wilson , who he said underwent the procedures during the pandemic.

"I was essentially tricked into signing documents for one of my older boys," Musk told Peterson in a Daily Wire interview during which he referred to his child by their deadname. "This was really before I had any understanding of what was going on, and we had COVID going on, so there was a lot of confusion and I was told (Musk's child) might commit suicide."

The SpaceX founder claimed the process is done to children "who are far below the age of consent" and said he agreed with Peterson's belief that anyone who promotes the practice should go to prison.

"I was tricked into doing this," Musk said. "I lost my son, essentially. They call it 'deadnaming' for a reason. The reason they call it ‘deadnaming’ is because your son is dead."

Musk went on to say that the experience set him on a mission.

"I vowed to destroy the woke mind virus after that," Musk said. "And we’re making some progress."

Vivian Jenna Wilson cut ties with father in 2022

Wilson was legally granted her name and gender change at age 18 at the Santa Monica courthouse in California on June 22, 2022.

She said the name change was due to gender identity and an apparent dislike of Musk, according to a petition filed on April 18, 2022, in Los Angeles County Superior Court.

"I no longer live with or wish to be related to my biological father in any way, shape or form," Wilson wrote in the petition.

Wilson's mother is Justine Wilson, a Canadian author who divorced Musk in 2008; the couple shares six children.

Musk called 'woke mind virus' threat to modern civilization

Musk has previously criticized what he calls "woke mind virus"  in a December 2021 interview with conservative outlet The Babylon Bee, where said called it "a world without humor"  and "arguably one of the greatest threats to modern civilization."

Musk announced his intent to buy Twitter for $44 billion on April 25, 2022 , and closed the deal about six months later . He promised to restore "free speech" on the platform and has increased his conservative political commentary since the purchase.

Earlier this month, Musk said he fully endorsed former President Donald Trump after the attempted assassination at a Pennsylvania rally on July 13.

Gender-affirming care is a valid, science-backed method

Gender-affirming care  is a  valid, science-backed method  of medicine that saves lives for people who require care while navigating their gender identity. Gender-affirming care can range from talk or hormone therapy to  surgical intervention .

Some experts claim that that  gender-affirming care  should be viewed like other forms of medicine where methods of treatment can be debated and discussed rather than the validity of it's need.

"In any medical field, we're continuously improving the care, changing the care, developing new  guidelines , developing research," Dr. Ximena Lopez, a pediatric endocrinologist in California, previously told USA TODAY. "So it should not be a surprise that it's the same in gender care."

Transgender adults  make up less than 2% of the U.S. population with about 5% of young adults identifying as  transgender  or nonbinary.

"We need to take a step back from acknowledging yes, they might have side effects, but that's why they're not done so flippantly," Dr. Ramiz Kseri , assistant professor in the department of clinical sciences at Florida State University College of Medicine, previously told USA TODAY. "That's why there is conversation about it, there is discussion, in terms of which outcomes are desired, and which outcomes are not desired."

Contributing: Natalie Neysa Alund, Jessica Guynn and David Oliver, USA TODA Y

‘Killed by woke mind virus’: Son tricked into taking puberty blockers, says Elon Musk

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Elon Musk News

The SpaceX CEO condemned gender-reassignment surgery, labeling it as 'child mutilation and sterilization.'

Tesla and SpaceX head Elon Musk shared in an interview with Canadian conservative commentator Jordan Peterson that his estranged transgender daughter, Vivian Jenna Wilson, fell victim to, or was “killed” by, what he described as the “woke mind virus.”

Musk claimed this influence led her to pursue gender-affirming care during the pandemic. The owner of X condemned gender-reassignment surgery, labeling it as “child mutilation and sterilization.”interview, Musk told Peterson, “I was essentially tricked into signing documents for one of my older boys,” referring to his child by their deadname. “This happened before I fully understood the situation, amidst the chaos of COVID.

Deadnaming involves using a transgender or non-binary person’s pre-transition name. This practice is considered harmful, as it can lead to harassment and discrimination against transgender individuals.Musk claimed this experience motivated him to fight what he calls the “woke mind virus.” He added, “I vowed to destroy the woke mind virus after that. And we’re making some progress.

“I no longer live with or wish to be related to my biological father in any way, shape, or form,” Wilson declared in the petition. Wilson’s mother, Justine Wilson, a Canadian author, divorced Musk in 2008.The term “woke mind virus” remains somewhat vague, but it generally refers to what critics see as excessively progressive or “woke” practices that they believe negatively impact society and media.

Gender Reaffirming Surgery Spacex X

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Female to Male Gender Reassignment Surgery (FTM GRS)

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

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

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

Interested in having this procedure?

Useful Information

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

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

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

Inpatient/Outpatient

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

Additional Information

What are the risks.

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

What is the recovery process?

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

What are the results?

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

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Gender-affirming care for minors

In Singapore, gender-affirming care for minors (under 21) requires the consent of both parents, even if those parents are separated.

Exceptions may be made for extraordinary circumstances (e.g. if one or both parents are dead or mentally incapacitated).

There is no minimum age to be evaluated by a psychiatrist for gender dysphoria (which is required for HRT), although parental consent will be required for those under 18.

After receiving a diagnosis of gender dysphoria, trans youths with both parents’ consent can access HRT through private healthcare if they are above 16, and through public healthcare if they are above 18.

Obtaining gender-affirming care for minors

The private healthcare route.

• If you have your parents’ support and they can afford it, you can visit a private psychiatrist to be evaluated for gender dysphoria. This will likely require several sessions, with each costing a few hundred dollars. Some psychiatrists are also able to speak with your parents to explain what it means to be transgender and address concerns they may have.
• Once your psychiatrist has deemed you suitable to begin HRT, you can then visit a private endocrinologist. Note that private endocrinologists may have their own age requirements.
• If you are above 18, you can also bring the psychiatrist’s diagnosis to a public hospital endocrinologist (via a polyclinic referral if you are a Singapore Citizen or PR), but results may vary as they may not accept diagnoses from private psychiatrists.

Through the public healthcare route

• HRT approval for trans youths under 21 is much stricter, especially given the global climate with regards to transitioning for trans youths. You will be subject to a lot more evaluation than trans adults, and there are people who have been rejected for HRT despite having both parents’ consent.
• If you are under 18, you may receive a diagnosis but will need to wait until 18 before you can begin HRT even if both parents approve.
• If your parents do not consent to HRT, you can still use these appointments later on as supporting documentation to gain accommodations (e.g. for National Service)

Puberty blockers

A minority of transgender youth who desire medical transition and who have been assessed by doctors as suitable candidates for treatment may choose to undergo temporary puberty suppression with puberty blockers. This will solely halt the development of secondary sex characteristics, allowing them time to physically and mentally mature before making the irreversible decision to undergo either typical male or female puberty.

Subsequent HRT will then allow them to develop bodies that – genitalia aside – are phenotypically identical to others of their gender. Trans women will be able to retain high voices; trans men will not have to grow breasts. Both will develop the height, musculature and skeletal structure typical for their identified gender. This eliminates most sources of body dysphoria, increasing quality of life. It will also make it much easier for them to blend into society, significantly reducing their risk of discrimination, abuse and violence and give them the ability to live a normal life, should they so choose.

At this point, assessments are rigorous enough that roughly 98% of these youths persist in trans identification as adults, indicating that non-treatment is far more likely to do harm than good, and allaying common fears that many may cease to be trans in adulthood.

The remaining 2% include those who are still trans but have decided not to medically transition at that point, those who realise they are non-binary, and a few who no longer consider themselves trans. These youths can then go off the blockers and proceed with regular puberty, retaining their fertility, and will likewise look no different from others of their sex.

A large scale study of 20,619 transgender adults aged 18-36 found that past access to pubertal suppression, for the 16.9% who desired them (2.5% of that subset had access), was associated with reduced lifetime suicide ideation and improved mental health outcomes.

Prior long-term studies of transgender youth who undergo puberty blockers treatment have consistently produced extremely positive results. In one study , 55 transgender youth were monitored over a period of about 8 years from the administration of puberty blockers at an average age of 13 to hormone therapy at ~17 to surgery at ~21, after which they scored equal or better on assessments of mental health compared to their non-trans peers. This is especially significant in light of the astronomical rate of mental illness and suicide that has long been observed in transgender youth denied treatment until adulthood.

As with all medication, there is a risk of side effects. Each youth’s individual health profile, existing conditions and family medical history are thus also taken into consideration alongside the severity of dysphoria and other concerns. These risks may need to be separately monitored and managed as appropriate.

Side effects are more common with extended use of puberty blockers over many years, as is the case for children with precocious puberty, and it is not recommended to be on them for more than 2-3 years. Where a youth has been on puberty blockers for several years or experienced concerning side effects, had found relief from dysphoria through the blockers, and has expressed a strong and persistent gender identity across many years that shows no sign of changing, earlier access to HRT may be considered appropriate on a case-by-case basis.

Puberty blockers are not available in Singapore for transgender youths in the public health system. For information on how you can obtain puberty blockers through a private specialist, reach out to us at [email protected] .

Things to consider for trans youth

There is no single “right” way to transition.

Some trans people experience little or no body dysphoria and are content with social transition without medical intervention. This is especially common for those who are non-binary.

If this is the case for you, and you are happy with your body as it is, you should never feel pressured to pursue HRT out of the belief that it is what a trans person “should” do. The goal of transition is for you to be comfortable with your body and identity.

If you are happy with yourself as you are but feel that you need to look a certain way to be taken seriously as your gender, that is a valid concern, but should not be the basis for medical decisions. Consider speaking about this with a counsellor, or find other ways to influence how others see you – such as through make-up (for trans girls and other transfemmes) or working out (for trans boys and other transmascs), or even explicit indicators like pronoun pins. For trans youths, this – alongside clothing, hairstyles and mannerisms – may be sufficient for you to be perceived as your gender.

Socially, trans students in Singapore face immense challenges within the school system and are unlikely to be accommodated on issues of uniform and toilet access. If you are presently enrolled in a local public school, you may wish to consider options like withholding your transition until after graduation, living as your gender only among friends or outside of school, or going on HRT without full social transition if your dysphoria is too severe.

• This could look like a trans girl going on HRT to ease her dysphoria and coming out to friends and classmates, while continuing to wear the boys’ uniform at school. This is often harder for trans boys, who would stand out more in the girls’ uniform if they are on HRT, but some schools are willing to make accommodations to allow PE uniforms instead.

If you legally change your name, you can update your name in your school records and be addressed as such. Schools would otherwise continue to refer to you by your legal name, which would also be the name that appears in your transcripts and certificates.

International schools are known to be more accommodating and even strongly supportive of transgender students. This nonetheless differs from school to school.

Managing stress

Transitioning is often deeply stressful, especially in Singapore and especially for youths, all the more if you do not have a supportive environment. If you are already undergoing considerable stress in other areas of your life, do take that into account when considering when and how to transition.

• If you have severe gender dysphoria, the relief from transition may help you better cope with stresses in other areas of your life, even alongside the new challenges that will come from transitioning.
• If however your gender dysphoria is minimal, the relief you get from transitioning may not be enough to overcome those additional stresses and challenges. In that case, you may wish to wait until you are older, since transitioning as an adult over 21 is much easier in many ways and also gives you more control over your own transition. This is especially important if you desire a less typical transition, such going on low-dose HRT or pursuing surgeries without HRT.

What you can do in the meantime

It is difficult to access psychological care and support for gender dysphoria without parental approval. However, some services have a lower age limit – support and befriending services begin at 16 for TransBefrienders.

If your parents can afford it and are open to it, you can ask to go to a LGBTQ-affirming counselling or therapy service. Some provide family counselling sessions that you can attend together with your parents

Coming out to parents – I’ll Walk With You

I’ll Walk With You is a comprehensive resource guide for parents of transgender children and is available in all four of Singapore’s official languages – Malay, English, Chinese and Tamil.

It is available in PDF form here.

If your parents would like additional support, they can also reach out to us for information.

Due to the sensitivity of the information involved, feel free to contact us if you wish to find out more about pursuing transition via the public healthcare system. You can reach us by email at [email protected].

Disclaimer: Information on this site is for general information only. It does not constitute legal or medical advice and is not a substitute for obtaining advice from a qualified professional. We do not represent or warrant that this information is suitable, reliable, complete, accurate or up-to-date.

Iran will pay for gender-transition surgery, but it comes at a cost — your dignity

Life under Iran's LGBTQ+ paradox

As a child growing up in Tehran, Shayan Varamini didn't know what it meant to be transgender.

Assigned female at birth, Varamini always felt drawn to dressing boyishly. He'd once had romantic feelings for a girl in his school, leading him to assume he might be a lesbian.

But in Iran , where same-sex relations can lead to imprisonment, corporal punishment, and even execution, he needed to be sure.

When he turned 18, just over a decade ago, Varamini sought guidance from a psychologist, who told him he was not a lesbian. Instead, he was diagnosed with "gender-identity disorder," an outdated term used to describe being transgender.

Because of its classification as an illness, Varamini's diagnosis came with a proposed treatment — what the Iranian government calls "sex-reassignment surgery."

After a lengthy bureaucratic procedure, the Iranian state not only recognized Varamini's transition but also helped finance it.

Varamini's surgeries were covered by his public health insurance, along with a modest grant the state paid him upon completion. Varamini paid 250,000 tomans, or about $60, out of pocket for the surgeries.

This generous coverage has led some to describe Iran, a deeply religious and socially repressive culture, as an unlikely "hub" for gender-affirming care.

While exact figures are hard to come by, a 2022 report by the UK's Home Office said that about 4,000 gender-affirming surgeries were performed each year in Iran. In 2007, The Guardian reported that Iran ranked second only to Thailand in the number of gender-affirming surgeries performed.

But transgender Iranians told Business Insider that this portrayal doesn't capture their reality — one marked by humiliation, rejection, and even violence.

On the surface, Iran's transgender policy might seem surprisingly liberal, an anomaly in the Muslim world. But a closer look reveals a darker picture.

Iran permits and funds gender-affirming care while discriminating against lesbian, gay, and bisexual people, along with others who identify as queer.

In a country that has executed people for being gay , what's behind this paradox?

Thanks in part to an edict issued by a Muslim ruler in the 1980s, being transgender in Iran is considered a medical disorder, while being gay is considered a sin.

Some Iranian leaders have made it a mission to erase homosexuality in the country — and activists believe that the government funds gender-affirming surgery in part to accomplish that.

But even once a person has transitioned, they are by no means safe.

Earlier this year, Tehran's city council started creating no-go zones for transgender people. Antidiscrimination laws for LGBTQ+ people don't exist in Iran, nor is there any recognition of genders beyond the binary male and female.

Becca Kia, who now lives in the US, postponed her transition until leaving Iran, recognizing that the country's rigid definitions of sexuality and gender left no room for her.

"Trans people are being suppressed," she told BI. "Like trans lesbian women or trans men who are gay, they cannot transition unless they submit to that rule that, OK, I'm a trans man, but I'm attracted to a woman."

Anti-gay laws

In Iran, same-sex relations are strictly prohibited by law , which doesn't differentiate between consensual and nonconsensual acts.

Punishments vary based on the roles people play in sexual encounters. Under the Islamic Penal Code, engaging in penetrative sex could result in a punishment of up to 100 lashes or, in some cases, the death penalty. Sexual intercourse between women carries a penalty of up to 100 lashes, while those who engage in lustful kissing or touching may face up to 74 lashes.

The Iranian government does not publicize its punishment of gay or lesbian people. However, a 2021 report by Eleos Justice and the Capital Punishment Justice Project estimated over 250 people were executed for same-sex conduct between 1979 and 2004, and at least 79 people have been executed since 2004.

Individuals who identify outside their assigned gender are at risk of these penalties — unless they undergo a physical transition.

"If I were caught in a compromising situation with a man, the sodomy punishments would apply," Raha Ajoudani, a trans woman who is sexually interested in men, said.

On a video call earlier this year, Ajoudani brushed her blond bob behind her ears, showing off her perfectly manicured nails. She'd recently had a tense interaction with the Iranian morality police , but she said she's experienced far worse.

Ajoudani dresses femininely and uses she/her pronouns , but because she has refused to undergo surgical procedures, legal documents mark her as male.

Despite pressure from the authorities, Ajoudani said she refuses to get surgery because she doesn't "have a problem with my body."

The surgical blade is a legal must for trans people Raha Ajoudani

When she was 15, Ajoudani said she was made to visit a state psychologist, only to be presented with an ultimatum.

Related stories

"They told me I had two options," she told BI. "Either go back to what society expected of me or undergo surgery."

She didn't do either, and in October 2022 she was detained by the morality police.

Ajoudani said she fell victim to a honey-trap scenario in which a man she was talking to online lured her to a public spot, where two dozen officers apprehended her.

In December 2022, she was detained again.

In that instance, Ajoudani said that Revolutionary Guard Corps officers raided her home, confiscated her phone, and searched her belongings. She was dressed in a miniskirt and wearing makeup when arrested and was dressed the same when placed in solitary confinement in a men's prison.

Ajoudani initially received a 30-month prison sentence and a temporary travel ban for insulting "Islamic sanctities," among other charges.

Ajoudani told BI that the court determined no prison facilities were equipped to house her — a transgender person deemed to have "mental and sexual issues" because she had not undergone gender-affirming surgeries.

"The surgical blade is a legal must for trans people," Ajoudani said. "Either you undergo it, or you are completely deprived of your civil rights, and that is exactly what they did to me."

A historic fatwa

In 1987, the leader of Iran's Islamic Republic, Ayatollah Ruhollah Khomeini, issued a fatwa — an Islamic legal decree — declaring that gender-affirming surgery did not violate Islamic law.

The key player behind Khomeini's decree was Maryam Khatoon Molkara, a trans woman whose story convinced him to declare the fatwa.

When Molkara was 2 years old, her mother found her mimicking putting on makeup by applying chalk to her face. As she grew older, Molkara knew she was transgender, but as a devout Muslim , she struggled to understand how she could reconcile her gender dysphoria with her faith.

She began corresponding with religious figures, including Khomeini, a respected Shiite jurist living in exile in Iraq at the time, seeking religious blessing to undergo a transition.

In 1979, a revolution shook Iran , leading to the establishment of the Islamic Republic. The new government enacted a legal code rooted in Sharia law, which ushered in a period of profound adversity for LGBTQ+ people.

Under the new laws, Molkara lost her job, had to dress like a man, was forcibly given male hormones, and was confined for a time to a psychiatric facility.

But she persisted in her attempts to communicate with Khomeini, who had risen to become the supreme leader of the newly formed republic.

"I knew I could get the operation easily enough in London, but I wanted the documentation so I could live," she told The Guardian in 2005.

Dressed in a man's suit and clutching a Quran, she confronted Khomeini at his compound in Tehran to plead her case. At first, she was beaten by security guards, but seeing the commotion, Khomeini's relatives intervened, granting her an audience with the ayatollah.

Khomeini provided her with a letter giving her religious authorization to proceed with the surgeries. This was the start of a new era in which transgender Iranians could physically transition.

Home visits and scrutiny

Nonetheless, getting permission to proceed with the surgeries in Iran is no easy feat.

People seeking government support for transitioning must consent to home visits and scrutiny of their private lives, according to a document published by the State Welfare Organization of Iran and seen by BI.

And that's just one facet of the invasive, arduous, and often degrading process.

A 2023 report by Australia's Department of Foreign Affairs and Trade said obtaining approval for the surgery in Iran may take "several years of public court hearings, virginity tests, and mandatory counseling."

Those seeking surgery may bounce back and forth between the Legal Medicine Organization — a medical institution within the judiciary — and the court system while undergoing various tests to determine whether they meet the criteria for Iran's version of a gender-dysphoria diagnosis.

Pooya Mohseni, an Iranian American actor and trans activist, recalled the humiliation of being "interrogated" in 1994 by a panel of psychologists.

"The questions were so graphic that my mom, at some point, left the room," she told BI.

A questionnaire handed to patients by a Tehran clinic, reviewed by BI, prompted psychologists to ask about a person's "wet, sexual dreams" and whether "cross-dressing" sexually excited them.

It also asked whether they had been sexually abused or grew up in a "female-headed" household, and it suggested that practitioners check for "other sexual deviations."

The questionnaire requested a chromosome test, pelvic and abdominal ultrasounds, and hormone testing.

A medical document from the same clinic, also reviewed by BI, showed the results of a karyotype test, which checks a person's chromosomes for any "abnormality."

Homosexuality as a sin

Javad Sadidi, a Mashhad surgeon who specializes in gender-affirming surgeries, told BI that the process takes a minimum of two years.

It's so demanding, he said, in part because it's used as a filter to distinguish between transgender people and those seeking the surgery for different reasons, such as gay and lesbian people hoping to gain legal rights.

Sadidi said that gay people "never" slipped through.

Past reports, however, have accused Iranian authorities of coercing gay people into transitioning as part of a mission to eradicate homosexuality in the country.

In 2007, Mahmoud Ahmadinejad, Iran's president at the time, said in a speech at Columbia University: "In Iran, we do not have homosexuals like in your country."

Elina, a 33-year-old masculine-presenting Iranian lesbian who asked that their last name not be published for safety reasons, told BI that they saw this attitude in action.

They recalled a psychologist trying to persuade them that they were transgender.

"I was not uncomfortable with my body," Elina said, adding that the therapist thought all gays and lesbians were trans.

Elina, who refused to undergo the procedures, eventually left the country.

Shadi Sadr, an Iranian human-rights lawyer and a cofounder of Justice for Iran, told BI that direct coercion of gay people into transitioning was less common than in the past but that societal pressures remain strong.

"Against the context where homosexuality is not only a sin but a crime, many people in the LGBTQ+ community see that, going through the process of sex reassignment, they would gain relative freedom and human rights," she said.

"That's the whole coercive situation," she said.

An independent expert tasked by the United Nations to examine human-rights issues in Iran painted a bleak picture of the quality of gender-affirming care for Iranians in a March 2015 report

It described a system that was "clearly substandard and not in line with professional norms." It said people were often left with complications like severe bleeding, infections, scarring, and abnormally shaped sexual organs.

Soheil, an Iranian whose last name BI is withholding for his safety, underwent a mastectomy , oophorectomy, and hysterectomy 13 years ago at an Iranian public hospital in Karaj.

He said he received about $3,000 toward the surgery from the state, but the operations left him with lasting scars and health complications.

Soheil, who's now living as a refugee in Canada, is hoping to have corrective surgeries to repair the botched work done by Iranian surgeons.

They do garbage, garbage surgery Soheil

Anecdotal evidence from BI's sources suggests that only a few surgeons are trained in gender-affirming surgeries.

Indeed, there aren't many surgeons at all — a Lancet Commission on Global Surgery reported that Iran has 1.7 surgeons per 100,000 people, compared to 36.1 in the US.

"They do garbage, garbage surgery," Soheil said.

He has a "big hole" in his chest where muscle tissue was removed, he said. "When I go somewhere and need to remove my shirt, I feel embarrassed."

Soheil's experience was not just physically traumatic. From the outset, he said, nurses subjected him to harassment and ridicule. One nurse messed with his catheter, taunting him repeatedly about his decision to transition, he said.

He also recounted the story of a friend who decided to get surgery at a private Iranian hospital after being put off by horror stories about the public system.

After the surgery, the friend was unable to afford a stay in the hospital, so he checked himself into a motel, Soheil said. "He called one of his friends, saying that he didn't feel OK," Soheil said. "When his friend went, he had passed away."

Not a trans haven

Being ridiculed and othered is common for Iran's LGBTQ+ populations , said Varamini, the transgender man who had his surgery paid for by the state.

That's why, after his own transition, he worked with the State Welfare Organization of Iran to offer support to fellow transgender Iranians.

Later, he established his own organization, the Mahtaa Institute, which provides clandestine support to LBGTQ+ communities and sex workers . (He said the government heavily monitors his organization.)

While Varamini is grateful for his transition, he's confronted daily by the harsh realities others face.

Iran does offer opportunities for some transgender individuals, he said, but for many others, life is nothing short of "hellish."

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