Scientific Studies

We present a selection of scientific studies on the transgender community from roughly the past decade, covering a variety of topics. We have tried to highlight the more significant studies while excluding those that are too old, behind a paywall, too similar to other papers, or have sample sizes that are too small. (For a more comprehensive collection, you can refer to this spreadsheet from a member of the public who since 2013 has been collecting trans-related papers.)

• Support for gender transition and gender-affirming hormone therapy
• Support for gender-affirming surgeries
• Safety of gender-affirming hormone therapy
• Impact of policies and social support
• Transgender youths – support for gender-affirming care
• Transgender youths – mental health
• Transgender children
• Neurology of gender and gender dysphoria
• Development of gender dysphoria
• Studies of trans populations in Asia
• Regret and detransition
• Miscellaneous

Support for gender transition and gender-affirming hormone therapy

(Note: As the past few decades of studies have unanimously shown that gender-affirming hormone therapy is beneficial for transgender adults, more recent efforts have shifted instead to focusing on youths, which is why this section does not have more recent papers.)

• What does the scholarly research say about the effect of gender transition on transgender well-being? (Cornell University, 2018 – includes links to all 55 studies, some of which we separately highlight below)
  93% of published peer-reviewed studies from 1991-2017 found that gender transition improved the overall well-being of transgender people. The remaining 7% showed mixed or null findings. No studies found that it causes overall harm.
• A Cross-Sectional Multicenter Study of Multidimensional Body Image in Adolescents and Adults with Gender Dysphoria Before and After Transition-Related Medical Interventions (Becker et al., 2018)
  Findings suggest that medical interventions, especially gender-affirming hormones and surgery, are generally beneficial to the body image in individuals with gender dysphoria.
• Socio-demographic variables, clinical features and the role of pre-assessment cross-sex hormones in older trans people (Bouman et al., 2016)
  Trans women on cross-sex hormone therapy who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem and presented with fewer socialization problems.
• Effect of sex reassignment on mental well-being and quality of life (Mattila, 2015)
  Gender dysphoria is effectively alleviated by sex reassignment treatments. Quality of life is improved among the majority of patients, and regrets are rare. Psychiatric symptoms at the initiation of the transition process, discrimination, negative attitudes, losses in relationships, and complications in somatic treatments may deteriorate the social integration and quality of life.
• Long-Term Follow-Up of Adults with Gender Identity Disorder (Ruppin and Pfafflin, 2015)
  At follow-up (range of 10-24 years), participants (n=71) reported high degrees of well-being and good social integration with reduced dysphoria from transition. Participants exhibited significantly fewer psychological problems and interpersonal difficulties as well as strongly increased life satisfaction compared to the time of the initial consultation.
• Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt (Bailey et al., 2014)
  High rates of suicidal ideation (84% lifetime prevalence) and attempted suicide (48% lifetime prevalence) were observed. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk.
• Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study (Colizzi et al., 2014)
  HRT significantly reduced patients’ (n=118) psychiatric distress and functional impairment after 12 months (from 50% to 17% for anxiety; 42% to 23% for depression; 24% to 11% for psychological symptoms; 23% to 10% for functional impairment). The majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings.
• Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder (Heylens et al., 2014)
  Overall psychoneurotic distress decreased at the different points of assessments, with the most prominent decrease occurring after the initiation of hormone therapy. Significant decreases were found in the subscales of anxiety, depression, interpersonal sensitivity, and hostility. Scores resembled those of a general population after hormone therapy was initiated.
• Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People (Davis and Amand, 2014)
  Testosterone therapy is associated with a positive effect on mental health on measures of depression, anxiety, and anger for trans men, while chest surgery appears to be more important for the alleviation of body dissatisfaction.
• Disorders of gender identity: what to do and who should do it? (Barrett, 2014)
  Transsexualism is not usually indicative of psychopathology. In carefully selected individuals, with multidisciplinary support, a change of social gender role and cross-sex hormone treatment greatly improves the psychological and social state. Sustained improvement merits gender reassignment surgery. The key is early referral with subsequent primary care cooperation in the treatment plan.
• Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style (Colizzi et al., 2013)
  Untreated trans subjects had elevated cortisol awakening responses (CAR) at enrollment with expressed higher perceived stress and more attachment insecurity compared to normative data. After hormone treatment, CAR levels fell within the normal range, and patients expressed lower perceived stress at rates similar to normative samples.
• Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery (Gomez-Gil et al., 2013)
  Cross-sex hormonal treatment, family support, and working or studying were linked to a better self-reported quality of life.
• Hormonal Therapy Is Associated With Better Self-esteem, Mood, and Quality of Life in Transsexuals (Gorin-Lazard et al., 2013)
  Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater “psychological-like” dimensions of quality of life.
• Hormonal therapy satisfaction is associated with better quality of life in transsexual persons (Wierckx et al., 2013)
  Trans men and women had worse quality of life compared to the general population, but improvements were associated with hormone therapy, surgical satisfaction, and social and economic determinants such as income and educational levels.
• Endocrine treatment of transsexual persons: extensive personal experience (Leinung, 2013)
  Cross-sex hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages, lessening the negative impact of gender dysphoria on mental health and leading to improved social outcomes.
• Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria (Fisher et al., 2013)
  For trans women, body-related gender dysphoria may be effectively diminished with the administration of hormone therapy even without the use of genital surgery.
• Transsexualism: Treatment Outcome of Compliant and Noncompliant Patients (Pimenoff and Pfafflin, 2011)
  A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on their own initiative without a recommendation from the psychiatrist.
• The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals (Amand et al., 2011)
  Trans men (n>400) who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.

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Support for gender-affirming surgeries

• Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study (Park et al., 2022)
  Body congruency scores improved significantly in 40 years’ postoperative settings, with average scores ranging from 84.2 to 96.2. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.
• Association Between Gender-Affirming Surgeries and Mental Health Outcomes (Almazan et al., 2021)
  In this secondary analysis of the 2015 US Transgender Survey (n=27, 715), respondents with a history of gender-affirming surgery had significantly lower odds of past-month psychological distress, past-year tobacco smoking, and past-year suicidal ideation compared with those with no history of gender-affirming surgery.
• Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study (Branstrom et al., 2019)
  Increased time since last gender-affirming surgery was associated with reduced mental health treatment.
• Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study (Poudrier et al., 2019)
  Following top surgery, measures of quality of life and sexual confidence improved significantly (n=58). 86% reported improvement in gender dysphoria-related mental health conditions. All but one reported that it had an overall positive impact on their life.
• Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study (van der Grift et al., 2017)
  Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications.
• Body Image in Transmen: Multidimensional Measurement and the Effects of Mastectomy (van de Grift et al., 2016)
  Mastectomy improved body satisfaction most strongly, although respondents reported improvements in all domains including decreased dysphoria, higher quality of life and improved feelings of self-worth.
• Psychosocial outcome and quality of sexual life after sex reassignment surgery: An Italian multicentric study (Prunas et al., 2015)
  We found high levels of satisfaction in all the areas explored and levels of psychological and social well-being comparable to those of the general population.
• Values and preferences of transgender people: a qualitative study (Schneiders, 2014)
  Major psychological distress was reported by those wishing to undergo surgery but unable to do so. Great relief and improvement to well-being was reported by those able to undergo surgery.
• Patient Satisfaction with Breasts and Psychosocial, Sexual, and Physical Well-Being after Breast Augmentation in Male-to-Female Transsexuals (Weigert et al., 2013)
  Gains in breast satisfaction, psychosocial well-being, and sexual well-being after breast augmentation were statistically significant and clinically meaningful at 4 months after surgery and in the long term.
• Quality of life and sexual health after sex reassignment surgery in transsexual men (Wierckx et al., 2011)
  Results indicate transsexual men generally have a good quality of life and experience satisfactory sexual function after SRS.

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Safety of gender-affirming hormone therapy

• Bone health in adult trans persons: an update of the literature (Wiepjes et al., 2019)
  Short-term and long-term studies show that hormonal treatment does not have detrimental effects on bone mineral density in trans women and trans men. Low estradiol concentrations were associated with a decrease in bone mineral density in trans women.
• Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals (Weinand and Safer, 2015)
  Current literature suggests HRT is safe when followed carefully and monitored for certain risks, particularly venous thromboembolism for trans women and polycythemia for trans men. Both groups experienced elevated fasting glucose. There is no increase in cancer prevalence or mortality due to transgender HRT.
• A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones (Asscheman, 2011)
  A study of 1,331 trans people receiving HRT, median follow up of 18.5 years. Trans women had increased mortality mainly due to non-hormone-related causes such as suicide or HIV/AIDS, but current (not past) use of ethinyl estradiol may increase the risk of cardiovascular death. Trans men had no elevated mortality; use of testosterone in doses used for hypogonadal men seemed safe.

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Impact of policies and social support

• Gender-congruent government identification is crucial for gender affirmation (Malta et al., 2020)
  When compared with participants with no gender-congruent ID, those with all congruent IDs had lower prevalence of severe psychological distress, suicidal ideation, and suicide planning.
• Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations (Restar et al., 2020)
  Legal gender affirmation was significantly associated with lower reports of depression, anxiety, somatization, global psychiatric distress, and upsetting responses to gender-based mistreatment. Findings bolster calls to increase structural support for trans individuals, including enactment of state policies easing legal gender affirmation.
• Examining Associations Between State-Level Transgender Policies and Transgender Health (Du Bois et al., 2018)
  More structural-level transgender inclusion, for example, protection from discrimination in schools and ability to change name and gender on identifying documents, predicted better mental health, less alcohol consumption, and more recent health care utilization among transgender individuals.
• Experiences of Discrimination, Harassment, and Violence in a Sample of Italian Transsexuals Who Have Undergone Sex-Reassignment Surgery (Prunas et al., 2018)
  36% experienced at least one episode of harassment, violence, or discrimination. The workplace was reported to be the social area with the highest risk of discrimination and harassment (22% of participants). Reports of more than one incident of discrimination, harassment, and violence characterized the majority of participants in the MtF sample.
• Transgender Surgery—Not the Benchmark for Gender Marker Determination (Arnold et al., 2017)
  Because of the challenges related to gender-affirming procedures, it is critical that the legal status of transgender people never be determined by surgical history.
• Global health burden and needs of transgender populations: a review (Reisner et al., 2016)
  Trans populations are affected by a range of negative health indicators across all income levels. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local trans communities to ensure responsiveness of and cultural specificity in programming.
• Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada (Bauer et al., 2015)
  Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed). Parental support for gender identity was associated with reduced ideation.
• Gender-Related Victimization, Perceived Social Support, and Predictors of Depression Among Transgender Australians (Boza and Perry, 2014)
  Social support emerged as the most significant predictor of depressive symptoms, with higher levels of support linked to lower levels of depression. Second to social support, those who had had some form of gender affirmative surgery were significantly more likely to have lower symptoms of depression.
• Trans People’s Experiences of Mental Health and Gender Identity Services: A UK Study (Ellis et al., 2014)
  Untreated gender dysphoria (due to delays or refusals of treatment), unnecessary and intrusive questioning/tests, prejudicial attitudes by service providers, and restrictive treatment pathways all contribute to minority stress which is detrimental to the mental health and well-being of trans people.
• Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real? (Colizzi, 2014)
  A dissociative disorder of any kind seemed to be greatly prevalent (29.6%). When treated, patients reported lower dissociative symptoms. The question is whether dissociation is to be seen not as an expression of pathological dissociative experiences but as a genuine feature of gender dysphoria.
• Suicide Protective Factors Among Trans Adults (Moody and Smith, 2013)
  Social support from friends, social support from family, and optimism significantly and negatively predicted 33% of variance in participants’ suicidal behavior after controlling for age. Reasons for living and suicide resilience accounted for an additional 19%.

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Transgender youths – Support for gender-affirming care

• Psychosocial Functioning in Transgender Youth after 2 Years of Hormones (Chen et al., 2023)
  Appearance congruence increased for youths on HRT (n=315, aged 12-20) and was associated with increases in positive affect and life satisfaction, and decreases in depression and anxiety symptoms. Youths who had not undergone substantial gender-incongruent puberty had more positive outcomes.
• Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care (Tordoff et al., 2022)
  104 trans and non-binary youths (aged 13-20) receiving gender-affirming care had 60% lower odds of depression and 73% lower odds of suicidality over a 12-month follow-up compared to those without that care.
• Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults (Turban et al., 2022)
  Out of 27,715 respondents, trans people who had accessed gender-affirming healthcare in early adolescence had a 222% decrease in psychological distress and 135% decrease in past-year suicidal ideation compared to those who had desired but not been able to access the same.
• Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands (van der Loos et al., 2022)
  704 (98%) trans youths who had started gender-affirming medical treatment in adolescence continued to use gender-affirming hormones at follow-up, addressing worries that people who started treatment in adolescence might regret or discontinue such treatment.
• Psychosocial Characteristics of Transgender Youth Seeking Gender-Affirming Medical Treatment: Baseline Findings From the Trans Youth Care Study (Chen et al., 2021)
  Trans youths who had received puberty blockers (n=95, mean age 11.22) appear to be functioning better from a psychosocial standpoint than older youths who received only gender-affirming hormones (n=316, mean age 16.0), pointing to possible benefits of accessing gender-affirming treatment earlier in life.
• Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth (Mehringer, 2021)
  Chest dysphoria is a major source of distress and can be functionally disabling to transmasculine youth. Surgery performed during adolescence, including before age 18, can alleviate suffering and improve functioning.
• Association of Gender-Affirming Hormone Therapy With Depression, Thoughts of Suicide, and Attempted Suicide Among Transgender and Nonbinary Youth (Green et al., 2021)
  Out of 11,914 trans and non-binary youths, access to hormone therapy was associated with lower rates of depression, suicidal ideation and suicide attempts.
• Well-being and suicidality among transgender youth after gender-affirming hormones (Watson et al., 2019)
  A significant increase in general well-being and a significant decrease in suicidality were observed. These findings suggest that gender-affirming hormones are a valuable medical intervention with promising psychosocial outcomes for transgender youth.
• Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts (Olson-Kennedy et al., 2018)
  94% perceived chest surgery as very important, and chest dysphoria increased by 0.33 points each month between initiating testosterone therapy and undergoing surgery. Post-surgery, the most common complication of surgery was loss of nipple sensation, whether temporary (59%) or permanent (41%). Serious complications were rare. Self-reported regret was near 0.
• Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria (Costa et al., 2015)
  Psychological support and puberty suppression were both associated with an improved global psychosocial functioning in gender dysphoric adolescents.
• Gender dysphoria in children and adolescents: a review of recent research (Fuss et al., 2015)
  Recently published data on the long-term outcome of puberty suppression and subsequent hormonal and surgical treatment indicate that young people with gender dysphoria may benefit substantially with regard to psychosocial outcomes. Brain development studied by neuroimaging methods seems not to be disturbed by puberty suppression.
• Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment (de Vries et al., 2014)
  7-year follow up of 55 trans youths who received puberty-blockers followed by cross-sex hormone therapy and then gender reassignment surgery as adults. Well-being was found to be similar to or better than same-age young adults from the general population, a stark difference from the poor mental health typically observed in trans adolescents with limited/no access to medical transition.
• Gonadal Suppressive and Cross-Sex Hormone Therapy for Gender Dysphoria in Adolescents and Adults (Smith et al., 2014)
  Behavioural and emotional problems, depressive symptoms, and global functioning improve in adolescents receiving puberty suppression therapy. High rates of depression and suicide are linked to social marginalisation and barriers to care.

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Transgender youths – Mental health

• Self-Perception of Transgender Adolescents After Gender-Affirming Treatment: A Follow-Up Study into Young Adulthood (Arnoldussen et al., 2022)
  Self-perception was assessed before the start of gender-affirming hormone treatment (mean age = 14.65) and at least 6 months after gender-affirming surgeries (mean age = 20.70). Physical appearance and global self-worth improved significantly over the course of treatment. No domain worsened significantly. The domains of scholastic competence, social acceptance, athletic competence, and close friendship remained stable over time.
• Impact of gender-affirming care bans on transgender and gender diverse youth: Parental figures’ perspective (Abreu, 2022)
  Effects included (a) depression and suicidal ideation/risk of suicide, (b) anxiety, (c) increased gender dysphoria, (d) decreased safety and increased stigma, and (e) lack of access to medical care.
• Evaluation of Anxiety and Depression in a Community Sample of Transgender Youth (Gibson et al., 2021)
  Trans youths who had socially-transitioned had no significant group differences in self-reported depressive symptoms, self-reported anxiety symptoms, or parent-reported depressive symptoms as compared to controls.
• Trans adolescents’ perceptions and experiences of their parents’ supportive and rejecting behaviors (Johnson et al., 2020)
  Participants reported that rejecting and mixed parental behaviors contributed to a range of psychosocial problems (e.g., depression and suicidal ideation), while supportive behaviors increased positive wellbeing.
• School Restroom and Locker Room Restrictions and Sexual Assault Risk Among Transgender Youth (Murchison et al., 2019)
  The 12-month prevalence of sexual assault was 26.5% among transgender boys, 27.0% among nonbinary youth assigned female at birth, 18.5% among transgender girls, and 17.6% among nonbinary youth assigned male at birth. Youth whose restroom and locker room use was restricted were more likely to experience sexual assault compared with those without restrictions.
• Baseline Mental Health and Psychosocial Functioning of Transgender Adolescents Seeking Gender-Affirming Hormone Therapy (Kuper et al., 2019)
  Trans youths seeking HRT exhibit elevated rates of depression, anxiety, and competency difficulties, and demonstrate the need for investment in the clinical training and infrastructure to provide comprehensive care to this population.
• Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth (Russell et al., 2018)
  After adjusting for personal characteristics and social support, chosen name use in more contexts was associated with lower depression, suicidal ideation, and suicidal behavior.
• Mental Health and Self-Worth in Socially-Transitioned Transgender Youth (Durwood et al., 2016)
  Remarkably good mental health outcomes were found among socially-transitioned transgender children in the study. Findings suggest that the psychopathology historically found in transgender individuals may be due to society’s rejection and/or years of repressing or denying their gender identity, rather than intrinsic to being trans. This paper supports other recent findings that suggest a trans identity is not synonymous with high levels of psychopathology, and provides converging evidence that early family support is associated with positive mental health in transgender children.
• The Mental Health of Transgender Youth: Advances in Understanding (Connolly et al., 2016)
  Trans youth have higher rates of depression, suicidality and self-harm, and eating disorders when compared with their peers. Gender-affirming medical therapy and supported social transition in childhood have been shown to correlate with improved psychological functioning for gender-variant children and adolescents.

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Transgender children

• Gender Identity 5 Years after Social Transition (Olson et al., 2022)
  After 5 years, 94% of 317 socially-transitioned trans children still maintained the same binary gender identity; 3.5% had come to identify as non-binary, while only 2.5% had ceased to identify as trans.
• Consistency of gender identity and preferences across time: An exploration among cisgender and transgender children (Hassler et al., 2022)
  Results suggested some stability in children’s gender identity and preferences in middle childhood for both trans and non-trans children.
• Similarity in transgender and cisgender children’s gender development (Gulgoz, 2019)
  Trans children (n=317, aged 3-12) strongly identify as members of their current gender group and show preferences and behaviors strongly associated with that gender. Gender identity and gender-typed preferences generally did not differ from 2 control groups, with similar intensity and coherence over multiple areas.
• Predicting Early-Childhood Gender Transitions (2019)
  Gender non-conforming children who would later transition were highly similar to transgender children who had already socially transitioned and to control children of the gender to which they would eventually transition. Gender-nonconforming children who would not go on to transition were different from these groups.
• Gender Development in Transgender Preschool Children (Fast and Olson, 2017)
  Socially transitioned transgender children (n=36, aged 3-5) did not differ from age and gender-matched controls on gender preference, behavior, and belief measures.
• Mental Health of Transgender Children Who Are Supported in Their Identities (Olson et al., 2016)
  Socially-transitioned trans children had developmentally normal levels of depression and only minimally elevated anxiety compared to controls (n=73 for each group), in striking contrast to the high rates of psychopathology previously reported in trans children living as their natal sex.
• Gender Cognition in Transgender Children (PDF) (Olson et al., 2015)
  Trans children had response patterns mirroring those of two control groups, providing evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.
• Gender dysphoria and children (Nicholson and McGuinness, 2014)
  Limited research is available on gender dysphoria treatment protocols for children. However, preliminary studies suggest that early intervention improves the quality of life in individuals who are transgender. Ongoing research suggests that it may be possible to confirm gender dysphoria at an earlier age.

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Neurology of gender & gender dysphoria

• Brain Sex in Transgender Women is Shifted towards Gender Identity (Kurth et al., 2022)
  The underlying brain anatomy in transgender people is shifted away from their biological sex towards their gender identity.
• Neural Systems for Own-body Processing Align with Gender Identity Rather Than Birth-assigned Sex (Majid et al., 2020)
  Neuroimaging showed that both trans participants and controls activated similar self- and body-processing systems when viewing bodies that aligned with their gender identity rather than birth-assigned sex.
• Cross sex hormone treatment is linked with a reversal of cerebral patterns associated with gender dysphoria to the baseline of cisgender controls (Kilpatrick et al., 2019)
  Atypical cerebral patterns observed in trans men and women in parts of the brain associated with self-body perception were resolved to normal upon cross-sex hormone therapy.
• Testosterone Effects on the Brain in Transgender Men (Burke et al., 2017)
  We recently found that GD is associated with disconnected networks involved in self-referential thinking and own body perception. Cortico-cortical covariations between the left mesial frontal region and the left TPJ, which initially were increased in trans men, no longer differed from controls after testosterone treatment.
• Intrinsic network connectivity and own body perception in gender dysphoria (Feusner et al., 2017)
  Brain imaging was conducted on trans men viewing images of their own body morphed to be more male or female. Viewing more masculine morphs was associated both with greater self-identification and greater connectivity in certain brain networks, with neuroimaging results differing from male and female controls.
• Altered White Matter and Sensory Response to Bodily Sensation in Female-to-Male Transgender Individuals (Case et al., 2016)
  Trans men’s brains exhibited atypical activity compared to female controls when touched on the breast. No difference was observed between groups when touched on the hand. Findings suggest that dysphoria related to gender-incongruent body parts in FtM individuals may be tied to differences in neural representation of the body and altered white matter connectivity.
• White Matter Microstructure in Transsexuals and Controls Investigated by Diffusion Tensor Imaging (Kranz et al., 2014)
  Results showed widespread significant differences in mean diffusivity between groups in almost all white matter tracts. Female controls had highest mean diffusivities, followed by FtM transsexuals with lower values, MtF transsexuals with further reduced values, and male controls with lowest values.

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Development of gender dysphoria

• Genetic Link Between Gender Dysphoria and Sex Hormone Signaling (Foreman et al., 2020)
  A significant association was identified between gender dysphoria and ERα, SRD5A2, and STS alleles, as well as ERα and SULT2A1 genotypes in a study of 380 trans women and 344 male controls. Gender dysphoria may have an oligogenic component, involving several genes involved in sex hormone–signaling.
• 2D:4D Suggests a Role of Prenatal Testosterone in Gender Dysphoria (Sadr et al., 2020)
  Findings support the idea that high levels of prenatal T in natal females and low levels in natal males play a part in the etiology of gender dysphoria.
• The Use of Whole Exome Sequencing in a Cohort of Transgender Individuals to Identify Rare Genetic Variants (Theisen et al., 2019)
  DNA sequencing of 30 trans individuals found 21 variants in 19 genes that have associations with previously described estrogen receptor activated pathways of sexually dimorphic brain development.
• Early androgen exposure and human gender development (Hines et al., 2015)
  Individuals exposed to atypical concentrations of prenatal androgens have been consistently found to show increased male-typical juvenile play behavior, alterations in sexual orientation and gender identity, and increased tendencies to engage in physically aggressive behavior
• Increased Cross-Gender Identification Independent of Gender Role Behavior in Girls with Congenital Adrenal Hyperplasia: Results from a Standardized Assessment of 4- to 11-Year-Old Children (Pasterski et al., 2014)
  Girls exposed to high concentrations of androgens prenatally are more likely to show cross-gender identification.
• Postnatal testosterone levels and disorder relevant behavior in the second year of life (Saenz and Alexander, 2013)
  Greater postnatal testosterone levels in early infancy were predictive of more male-typical behaviors in the second year of life (i.e., more autism spectrum behaviors, less time vocalizing, and more Internalizing Problems), supporting the hypothesis that early infancy may be another critical period for the development of gender-linked behavior. (TransSG note: This and similar studies also provide potential explanations for the disproportionate rates of autism observed in trans male populations.)
• Sexual Differentiation of the Human Brain in Relation to Gender-Identity, Sexual Orientation, and Neuropsychiatric Disorders (Swaab and Bao, 2013)
  As sexual differentiation of the genitals takes place much earlier in intrauterine life than sexual differentiation of the human brain, these two processes can be influenced independently of each other. There is no proof that postnatal social environment has any crucial effect on gender identity or sexual orientation. We discuss the relationships between structural and functional sex differences of various brain areas and the way they change along with changes in the supply of sex hormones.
• The relationship between second-to-fourth digit ratio and female gender identity (Hisasue et al., 2012)
  Trans men had a 2D:4D finger length ratio that was significantly lower than in female controls. 2D: 4D influences are assumed to be established in early life and reflect testosterone exposure, suggesting a relationship between perinatal testosterone and male gender identity in trans men.
• Gender development and the human brain (Hines, 2011)
  Growing evidence shows that prenatal testosterone exposure contributes to the development of some human behaviors that show sex differences, including sexual orientation, core gender identity, and some, though not all, sex-related cognitive and personality characteristics.

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Studies of trans populations in Asia

• Experiences of conflict, non-acceptance and discrimination are associated with poor mental well-being amongst LGBTQ-identified individuals in Singapore (Toh et al., 2023)
  The authors investigated mental health status and its correlates in 2,350 LGBTQ individuals from the 2013 National LGBT Census Singapore sample.
• Mental illnesses and related vulnerabilities in the Hijra community: A cross-sectional study from India (Sartaj et al., 2021)
  The Hijra group showed high rates of mental disorder and substance involvement, related to poor quality of life and experiences of discrimination and disempowerment across multiple domains of life. 52% had experienced sexual or psychological violence.
• “Being Born like This, I Have No Right to Make Anybody Listen to Me“: Understanding Different Forms of Stigma among Thai Transgender Women Living with HIV in Thailand (van Wijngaarden and Fongkaew, 2021)
  Various forms of verbal, psychological and physical harassment were reported. Internalized stigma and stigma within the transgender community itself were significant. This paper suggests that transgender people themselves should better understand how the structure, culture and institutions of mainstream society instill, reinforce and perpetuate stigma against, within and among them. There is a need for advocacy directed toward manifesting societal emancipation of Thai transgender people – starting with legal reform.
• From silicone and hormone injecting to sex reassignment surgery: the precarious road to becoming female of transgender funeral performers in Ho Chi Minh City, Vietnam (Nguyen, 2019)
  This paper highlights the health hazards faced by members of this vulnerable social group as the result of using non-medically prescribed hormone therapy, silicone injection and sex reassignment surgery in the absence of legal provision regulating these practices.
• Denied Work: An audit of employment discrimination on the basis of gender identity in South-East Asia (PDF) (Winter et al., 2018)
  Experimental studies into job discrimination faced by transgender people in Thailand, Singapore, Malaysia and Vietnam.
• Factors Associated with Medical Doctors’ Intentions to Discriminate Against Transgender Patients in Kuala Lumpur, Malaysia (Vijay et al., 2018)
  A total of 436 physicians at two major university medical centers in Kuala Lumpur, Malaysia, completed an online survey. Medical doctors who felt more fearful of transgender people and more personal shame associated with transgender people expressed greater intention to discriminate against transgender people. Stigma-related constructs accounted for 42% of the variance and 8% was accounted for by sociodemographic characteristics.
• Mental Health of Transgender People in Hong Kong: A Community-Driven, Large-Scale Quantitative Study Documenting Demographics and Correlates of Quality of Life and Suicidality (Suen et al., 2018)
  Out of 106 respondents, more than half (50.9%) had a university degree or higher qualification; despite this, 43.4% had a monthly income below HK$6,000 (about SGD$1,055). 66% reported “fair” or “poor” quality of life; 67% of the sample (87.1% of those aged 15-24 years) had contemplated suicide; and 20.8% of the sample (35.5% of respondents aged 15-24 years) had attempted suicide. Those who were single, had a lower monthly income, and identified as transgender women reported lower quality of life; those who were younger and on a lower income expressed higher suicidality.
• Exposure to gender-based violence and depressive symptoms among transgender women in Cambodia: findings from the National Integrated Biological and Behavioral Survey 2016 (Yi et al., 2018)
  45.0% of participants had depressive symptoms, and 21.8% had severe depressive symptoms. After controlling for potential confounders, transgender women with depressive symptoms remained significantly more likely to report several negative experiences including social rejection, difficulties finding work, being denied or evicted from housing, difficulties accessing healthcare, physical abuse and having been fearful of arrest because of their trans identity.
• Challenges faced by marginalized communities such as transgenders in Pakistan (Shah et al., 2018)
  Trans people are socially excluded by the Pakistani society, experiencing high levels of physical abuse and discrimination in daily life. These make them vulnerable to risky behaviours such as commercial sex work, begging, drug abuse and suicidal ideation.
• It’s Complicated: Sociocultural factors and the Disclosure Decision of Transgender Individuals in Pakistan (Saeed et al., 2018)
  This study advances understanding of identity and disclosure decision of transsexual individuals by explicating the ways in which sociocultural factors are intricate part of their decision of coming out.
• Outcome and preferences in male-to-female subjects with gender dysphoria: Experience from Eastern India (Majumder and Sanyal, 2017)
  A retrospective study of treatment preferences and outcome in 55 MTF transgender subjects who were presented to the endocrine clinic.
• Outcome and preferences in female-to-male subjects with gender dysphoria: Experience from Eastern India (Majumder and Sanyal, 2016)
  This is a retrospective study of treatment preferences and outcome in 18 female-to-male (FTM) transgender subjects who presented to the endocrine clinic.
• A cross-sectional study of associations between casual partner, friend discrimination, social support and anxiety symptoms among Chinese transgender women (Yang et al., 2016)
  Chinese transgender women showed considerably high level of anxiety symptoms. They were exposed to significant transition challenges, such as high risk sexual partnership, excessive discrimination and a reduction in social support.
• Sex Partnership and Self-Efficacy Influence Depression in Chinese Transgender Women: A Cross-Sectional Study (Yang et al., 2015)
  Chinese transgender women experienced high levels of depression. Depression was best predicted by whether transgender women had a regular partner or a casual partner rather than transgender-related discrimination and transition status. Moreover, self-efficacy had positive effects on attenuating depression due to gender transition.
• Exploration of functional health, mental well-being and cross-sex hormone use in a sample of Thai male-to-female transgendered persons (kathoeys) (Gooren et al., 2013)
  Sixty kathoeys were interviewed regarding their use of cross-sex hormones and their family relationships.

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Regret and detransition

• Do Gender Assessments Prevent Regret in Transgender Healthcare? A Narrative Review (Ashley et al., 2023)
  The article concludes that there is no evidence that gender assessments can reliably predict or prevent regret better than self-reported gender identity and embodiment goals.
• Regret after Gender-Affirming Surgery: A Multidisciplinary Approach to a Multifaceted Patient Experience (Jedrzejewski et al., 2023)
  Among 1,989 individuals who underwent GAS, six (0.3%) either requested reversal surgery or transitioned back to their sex assigned at birth.
• Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments (McKinnon et al., 2022)
  Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.
• Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis (Turban et al., 2021)
  13.1% (n=2,242) of respondents who had ever transitioned reported a history of temporary or permanent detransition. History of detransition was associated with male sex assigned at birth, nonbinary gender identity, bisexual sexual orientation, and having a family unsupportive of one’s gender identity. 82.5% of those reported at least one external driving factor, the common ones including pressure from family and societal stigma and harassment. 15.9% reported at least one internal driving factor, including fluctuations in or uncertainty regarding gender identity.
• Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence (Bustos et al., 2021)
  A total of 27 studies covering 7,928 transgender patients who underwent any type of GAS were included. The pooled prevalence of regret after GAS was 1%. The prevalence of regret among patients undergoing transmasculine and transfeminine surgeries was <1% and 1% respectively, with the majority of regret due to poor surgical results or social stigma.
• The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets (Wiepjes, 2018)
  From 1972-2015, out of 6,793 people that visited the largest Dutch gender identity clinic serving 95% of the trans population in the Netherlands, only 0.6% of trans women and 0.3% of trans men who underwent gonadectomy were identified as experiencing regret.
• An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets (Dhejne et al., 2014)
  There were 15 regret applications from 1972-2010, corresponding to a 2.2% regret rate for both sexes. There was a significant decline of regrets over the time period.

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Miscellaneous

• Adult development and quality of life of transgender and gender nonconforming people (Walter et al., 2016)
  This review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research.
• Mental health and gender dysphoria: A review of the literature (Dhejne et al., 2016)
  Trans people attending transgender healthcare services appear to have a higher risk of psychiatric morbidity (that improves following treatment, often to normative levels), and thus confirms the vulnerability of this population.
• An exploration of transgender identity through the implicit association test (IAT) (Prunas and Bini, 2015)
  Trans adults’ results on the IAT-Gender Identity test had no significant differences from controls of the same gender.
• Identical Reared Apart Twins Concordant for Transsexuality (Segal and Diamond, 2014)
  An international survey of adult transsexual twin pairs reported transition concordance values of 33.3% (13/39) for identical male pairs and 22.9% (8/35) for MZ female pairs. By contrast, transition concordance values for fraternal male and female twins were zero or approached zero (1/36), consistent with genetic influence.
• Disordered eating and gender identity disorder: a qualitative study (Algars et al., 2012)
  Participants most frequently described striving for thinness as an attempt to suppress features of one’s biological gender, or accentuate features of one’s desired gender. Gender reassignment was primarily perceived as alleviating symptoms of disordered eating.

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