This is an odd one, given the almost universal claims, by trans folk, that transition has helped them to feel better about themselves, to function, in their job or in the world, where previously they did not function before, or, in some cases, simply to continue living. It is conceivable that perhaps there is some enormous global placebo effect leading trans people to claim transition is good for them when in fact it makes little difference. Evidence, though, suggests the opposite: that transition does improve quality of life significantly; although other factors, such as social rejection and discrimination can create other issues.
Overwhelming evidence for the benefits of transition
Evidence that the effects of transition are positive is overwhelming.
A systematic literature review1 of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being was carried out by Cornell University. This identified 56 studies that consist of primary research on this topic, together with a further 17 additional studies that consist of literature reviews and practitioner guidelines. From the core studies reviewed, 52 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. There were no studies concluding that gender transition causes overall harm.
The review concluded that there exists
“a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals. The literature also indicates that greater availability of medical and social support for gender transition contributes to better quality of life for those who identify as transgender.”
The Cornell study also delivered 8 key findings:
1. Available research clearly demonstrates that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals.
2. Positive outcomes of gender transition and related medical treatments for transgender individuals include improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidality, and substance use.
3. The positive impact of gender transition on transgender well-being has grown considerably in recent years, with parallel improvements in surgical techniques and social support.
4. Transition regrets are extremely rare and have become even rarer as surgical techniques and social support have improved. Pooled data from multiple studies suggests a regret rate ranging from .3% to 3.8% – and regret is more common where there is poor surgical or social support.
5. Factors predictive of success in respect gender dysphoria include adequate preparation and mental health support pre-treatment, proper follow-up care from knowledgeable providers, consistent family and social support, and high-quality surgical outcomes (when surgery is involved).
6. Transgender individuals, who cannot access treatment for gender dysphoria or who encounter unsupportive social environments, are more likely than the general population to experience health challenges such as depression, anxiety, suicidality and minority stress. Gender transition can mitigate these challenges: at the same time, the health and well-being of transgender people can be harmed by stigmatizing and discriminatory treatment.
7. An inherent limitation when it comes to transgender health research is the difficulty of conducting randomised control trials of treatments because of the individualised nature of treatment, as well as ethical issues involved in withholding an effective treatment from those who need it.
8. Research of transgender outcomes research has been limited historically by stigma against research in this field: but more is needed.
Origins of the myth
Given the near unanimity with which trans people speak about transition as a life-saver, it is hard to understand the insistence on the part of some people that transition should not happen or, in some cases, that trans individuals should undergo “therapy” to learn to cope with their feelings in respect of gender. The latter, it should be noted, is in fact “reparative therapy” which has been dismissed as harmful and unethical by most significant non-ideological bodies working in the field2.
Despite this, a report by Stonewall UK3 in November 2018 suggests that still some one in 20 LGB persons and one in 5 trans people in Britain today are being pushed towards some form or reparative therapy.
One of the major sources cited by those opposed to transition is a Swedish study4 that looked at long-term outcomes for trans people following gender re-assignment and has been mined extensively by individuals with a particular ideological point of view for anti-trans material – a phenomenon that the authors of this study have publicly criticised.
The key point picked up from this study is a conclusion that: “persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population”.
This, however, overlooks two key points also made by the authors of the study:
- “…the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment”, and
- “[this study] reflects the outcome of psychiatric and somatic treatment for transsexualism provided in Sweden during the 1970s and 1980s. Since then, treatment has evolved with improved sex reassignment surgery, refined hormonal treatment”
In other words, the key points that the authors of this study have gone to some lengths to develop are wholly consistent with the findings of the Cornell literature review as well as other work on trans populations. Trans people are at high risk of self-harm. Treatment – and transition – reduces this risk.
However, they remain at risk despite – not because of – treatment: and risk is reduced or increased according to other factors unconnected to transition, such as social acceptance and rejection by family and friends.
To attempt to twist this into a finding that transition does not help or even makes matters worse is ideology, not science.
This is further highlighted in an interview with lead researcher on this paper5, Cecilia Dhejne by Cristan Williams of Transadvocate in 2015. The entire interview is of interest, both in terms of understanding what the study does and does not say, and also as object lesson in how even positive research findings get twisted to deliver an anti-trans message. Here is Dhejne making very clear that claims made about what the study shows do not even apply to the whole study group. She writes:
“The study as a whole covers the period between 1973 and 2003. If one divides the cohort into two groups, 1973 to 1988 and 1989 to 2003, one observes that for the latter group (1989 – 2003), differences in mortality, suicide attempts, and crime disappear.”
1 – What we Know Project, “What does the scholarly research say about the effect of gender transition on transgender well-being?”, Cornell University website, 2018
2 – The Lies and Dangers of Efforts to Change Sexual Orientation or Gender Identity, US Human Rights Campaign, 2019
3 – LGBT in Britain: Health Report, published by Stonewall, November 2018
4 – Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885.
5 – Fact check: study shows transition makes trans people suicidal, by Cristan Williams, Transadvocate website, November 2015