gender reassignment surgery ohip

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Gender confirming surgery

How to apply for gender confirming surgery (also known as sex reassignment surgery) in Ontario. If you are eligible, this service is covered under OHIP .

As of March 1, you can seek an assessment for surgery from qualified health care providers across the province.

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Affirming gender identity.

Gender confirming surgery (also known as sex reassignment or gender affirming surgery) does more than change a person’s body. It affirms how they think and feel about their own gender and what it means to who they are.

Ontario is funding surgery as an option for people who experience discomfort or distress with their sex or gender at birth.

How to qualify

Ontario funds two types of gender-confirming surgery: genital and chest.

To qualify for funding, you must:

• be assessed and recommended for surgery by either one or two healthcare providers (e.g. a qualified doctor, nurse practitioner, registered nurse, psychologist or registered social worker)
• have a referral for surgery completed and submitted to the Ministry of Health and Long-Term Care by a physician or nurse practitioner; and
• have the surgery approved by the Ministry of Health and Long-Term Care before the surgery takes place

Approval for genital surgery

To be approved for genital surgery, you’ll need:

• one of the assessments must be from a doctor or nurse practitioner
• you have a diagnosis of persistent gender dysphoria
• have completed 12 continuous months of hormone therapy (unless hormones are not recommended)
• you have lived 12 continuous months in the gender role you identify with (for genital surgery only)

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

Approval for chest surgery

To be approved for chest surgery you’ll need:

• have a diagnosis of persistent gender dysphoria
• have completed 12 months of continuous hormone therapy with no breast enlargement (unless hormones are not recommended) if you’re seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Apply for surgery

To apply for gender confirming surgery, your doctor or nurse practitioner needs to fill out and submit the application along with the assessments and recommendations for surgery, to the Ministry of Health and Long-Term Care. The application is for patients seeking services in Ontario, out of province but within Canada or outside of the country.

Your doctor or nurse practitioner will let you know if your application is approved.

Once you receive approval from the ministry, talk with your health care provider to get ready for the surgery

Additional resources

You can find useful information from organizations, such as:

• find out about their ongoing project, Trans Health Connection
• consult their service directory
• find out about the Gender Identity Clinic (Adult)

Information for healthcare providers

Find out more about your role in providing gender-confirming surgery funded by Ontario.

New gender-affirming surgery clinic now accepting patients

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Plastic Surgeon Dr. Nicholas Cormier has dedicated nearly his entire career to caring for trans and non-binary patients.

The Ottawa Hospital understands that trans and non-binary people often face barriers accessing gender-affirming care. Faced with long wait times or even lack of access in the communities where they live, they may struggle to achieve their gender-affirming goals.

We are very pleased to announce that The Ottawa Hospital’s new gender-affirming surgery clinic is here to help. Launched in September 2023, it is the only clinic in Ontario and the second in Canada to offer all three of the following gender-affirming procedures:

• Facial surgery to make facial features more masculine or feminine
• Top surgery to remove breast tissue for a more masculine appearance or enhance breast size for a more feminine appearance
• Bottom surgery to transform the genitalia

The clinic’s lead and co-founder, Plastic Surgeon Dr. Nicholas Cormier, has some more wonderful news to share: “We’re currently accepting patient referrals from physicians,” he announces with a smile. “We’re ready to service Ottawa and the surrounding communities.” 

A truly collaborative effort

Before our clinic, patients seeking gender-affirming surgery in Ottawa could only access top surgery but not bottom or facial. Previously, a clinic in Montreal was the only location in Canada offering all three procedures.

“There’s just a massive gap in our health-care system for the treatment of the transgender population and people seeking gender-affirming care,” says Dr. Cormier. “What’s so groundbreaking about this new clinic is that everyone is coming together to address this shortcoming in our system.”

These partners include different surgical divisions at the hospital—plastic surgery, urology, obstetrics and gynecology—as well as trans health programs out in the community, such as the Centretown Community Health Centre’s Trans Health Program , which provides patients with a referral to our clinic, and CHEO’s Gender Diversity Clinic , which provided Dr. Cormier and his team with advice on setting up the clinic and also refers patients who have reached the age of 18.

These community programs are also important for the overall health and wellbeing of Ottawa’s trans and non-binary population. “Accessing gender-affirming surgery is just one small component of gender-affirming care,” says Dr. Cormier. “That’s where these community partners really come into play.”

Years in the making

For Dr. Cormier, the clinic is the culmination of many years of caring for the gender-diverse community.

“In my residency, I was always interested in gender-affirming care, and that led me to seek out a fellowship in San Francisco, where I was able to train with world-renowned experts in gender-affirming care,” he recalls. “And I’m really excited about bringing that to my hometown of Ottawa.”

And Ottawa’s gender-diverse community is (literally) in good hands, says Dr. Daniel Peters, Division Head of Plastic Surgery at The Ottawa Hospital. “Dr. Cormier has dedicated nearly his entire career to caring for this often underserved patient population. He has learned from the best of the best in this field and has the compassion to match his expertise. He joined The Ottawa Hospital’s Division of Plastic Surgery not long ago, and yet he has already shown tremendous leadership by getting this clinic up and running. That’s really a testament to his passion for helping people on their gender-affirmation journeys.”

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Ontarian takes OHIP to court for gender-affirming surgery funding

An Ontario resident is fighting the government to secure public funding for a specialized gender-affirming surgery argued to be "experimental" by the provincial health insurer.

The prospective patient, identified only as K.S. in documents filed with the provincial Health Services Appeal and Review Board (HSARB), is seeking coverage under the Ontario Health Insurance Plan (OHIP) for a penile-preserving vaginoplasty, a procedure in which a vaginal cavity is surgically created while keeping the penis intact. 

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“There have been so many times that I have had to justify myself to just be,” K.S. told CTV News Toronto in a statement submitted through her counsel. “People who aren’t trans or nonbinary don’t have to get that permission to exist.”

K.S., whose identity is protected under a publication ban, identifies as nonbinary. She presents as predominantly female and uses she/her pronouns, but does not align with the gender binary.

The procedure she seeks is not widely practiced. In what most consider a traditional vaginoplasty, the erectile tissue is inverted to create a vaginal cavity. In a penile-preserving vaginoplasty, the vaginal cavity is created using a skin graft instead. There is currently no peer-reviewed research on the outcomes of the technique, only offered by a small number of private clinics, none of which are in Canada.

Since 2023, K.S. has been engaged in a series of appeals put forth to the review board following an initial denial by OHIP to cover the surgery.

Having experienced gender dysphoria since her teenage years, K.S. first applied for funding in 2022, seeking to have the surgery performed at the Crane Center for Transgender Surgery in Austin, TX. OHIP denied her request, claiming it wasn't included in the list of insured services under OHIP. 

Without coverage, K.S. said undergoing the procedure would be nearly impossible – it costs tens of thousands of dollars that she doesn’t have.

READ MORE : What gender-affirming care is and how it can be life-saving

The legal battle that has played out in front of the review board has seen K.S. repeatedly make her case for why such a specialized procedure is medically necessary, measuring years of suffering through gender dysphoria against the assumed risk of a procedure not yet in the mainstream.

“The absurdity of managing to get through all the unjustly imposed barriers only to still be told that my surgical request is not valid has been heartbreaking,” she said.

When reached for comment, the Ministry of Health, which oversees health insurance in Ontario, said it could not comment on cases that are before the review board.

The case unfolds a critical juncture for transgender care in Canada  — just weeks ago, Alberta unveiled sweeping policy changes including a ban for all gender-affirming surgeries for minors aged 17 and under  — and, according to experts, could stand to inform national conversations of access to healthcare faced by non-binary population across the country.

Legal lens on gender identity

With no options to secure the surgery outside of insurance, K.S. appealed the government’s initial denial of funding in April 2023 .

“I felt I had no choice," she said. “There quite literally is no ‘do or don’t’ when it comes to treating gender dysphoria.”

Throughout the two-day hearing, lawyers representing the province argued that for a vaginoplasty to be considered an insurable service, a patient also needed to undergo a penectomy, as is considered the standard of practice in Ontario.

It called upon Dr. Yonah Krakowski, a sexual medicine surgeon at Women’s College Hospital, to provide expert testimony. Krakowski said that, while he supports patient autonomy, he believed wider expert opinion would deem the procedure sought by K.S. as “experimental” at this time.

Self-represented, K.S. argued, in part, that the denial singled her out based on gender identity and that nowhere in the provincial legislation or regulations was it a requirement that someone transition from one binary gender to another in order to be eligible for funding.

During the hearing, K.S. put forth “impressive legal challenges,” lawyer John McIntyre told CTV News. McIntyre, now representing K.S. in OHIP’s recent appeal.

“The process was incredibly challenging for her, as she was not only up against lawyers and the government, but she was having to fight against the view that her identity was not valid,” McIntyre said.

The challenge proved worth it – five months later, the three-person review panel ruled in K.S.’ favour . Her procedure, now deemed an insured service, would be paid for.

The victory didn’t come easily, K.S. said. “More than once during the legal process, the impacts of statements and opinions expressed by OHIP and its lawyers drove me to tears, messed with my sleep, and caused significant anxiety, unintended weight loss, and chest pains,” she said.

But it wasn’t long before OHIP filed its own appeal. Now, despite the unanimous ruling last year in her favour, K.S. must make her case for the panel for a second time — the thought of which brings her “despair.”

“The very idea that one should have to endure the significant legal process after already having to fight every single aspect of the medical system to just meet the criteria is unfair,” she said.

McIntyre called his client one of the “bravest people” he’s ever met.

“The only reason why she keeps pushing is the hope she can protect other trans and nonbinary folks from having to endure the same problems,” he said.

The case reflects wider issues: experts

This time, K.S. isn’t alone in her fight for funding. McIntyre and Egale, a non-profit organization advancing equality and justice for LGBTQ2S+ Canadians, are helping her navigate OHIP’s appeal.

In early January, Egale signed on as an intervenor in the case .

"The concern I have is this a tendency to treat these requests [...] as experimental," counsel for Egale, Daniel Girlando, told CTV News Toronto.

Girlando said the organization decided to step in, in part, because it feels that the ability to express one’s self in a way that doesn’t “necessarily reflect a binary gender” is important. “That means that some [OHIP applicants] will have customized requests,” he said.

The lawyer pointed to the World Professional Association of Transgender Health (WPATH), a leading authority on gender-affirming medical and surgical care, for guidance in this case. The WPATH’s Standard of Care guidelines note that “gender diverse presentations may lead to individually customized surgical requests some may consider ‘non-standard.’”

“In this evolving world, where standards are fast-changing and when we’re dealing with a small number of population, are we supposed to wait, what, years before there is enough data to deem these procedures experimental?” Girlando questioned.

Some experts say that’s exactly what Ontario should do.

Kinnon MacKinnon, an assistant professor at York University who studies the intersection of healthcare and gender, said in this case, the province will have difficulty establishing a risk-to-benefit ratio, as it has no data to draw from.

“In terms of medical ethics, clinical decision making, and funding, the risk-to-benefit ratio has to be favourable and with there being no studies, it would be hard to make the argument that the procedure is medically necessary,” he told CTV News in an interview last week.

“I think the priority right now should be to collect higher quality and long-term outcomes data to inform better care because I think we need a better sense of long-term outcome following certain surgeries,” he continued.

K.S. agrees more data collection is needed, but claims the province is failing to invest in the effort.

"They never get to collect the data because people like me are generally firewalled before we can get there," she said.

While K.S. said the harm done to her over the last two years has been “irreparable," she hopes to pave the way for others to express themselves freely. 

“Our fundamental existence is not optional," she said. "There’s a reason we see higher suicide rates for trans and non-binary people, and a positive ruling will save lives."

OHIP’s appeal will be heard virtually on Feb. 27.

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Transition-Related Surgery

Transition-related surgery (TRS) refers to a range of surgical options that can help people feel that their physical characteristics more closely reflect their gender identity or expression. These options can support one in feeling more comfortable in their body and may help to improve your mental wellness.

In order to receive provincially-funded transition-related surgeries, you will need a surgery assessment from one or two health providers, depending on the surgery, one of which being a qualified primary care provider like a Physician or Nurse Practitioner. 

If you have a primary care provider and would like to start a discussion with them about transition-related surgery, you can click here for tips on how to start that conversation. 

If you do not have a primary care provider and would like to access transition-related surgery, you can reach out to Centretown Community Health Centre’s Trans Health Program to get connected with surgery referral support.

Provincially Funded Transition-Related Surgeries

Disclaimer: this section uses medical terminology.

Upper Surgery (Chest or Breast Augmentation) needs one assessment by a qualified Physician or Nurse Practitioner. Lower Surgery (Genital Surgery) needs an additional assessment from any qualified Physician, Nurse Practitioner, Psychologist, or Registered Social Worker (Master’s Degree).

Under the Ministry of Health and Long-Term Care (MOHLTC), the following surgical procedures are provincially-funded:

For “Assigned Male at Birth” individuals:

• Vaginoplasty 
• Orchiectomy
• Augmentation Mammoplasty a (breast enlargement)*

*Patient must have completed twelve continuous months of hormone therapy with no breast enlargement unless hormones are contraindicated

For “Assigned Female at Birth” individuals:

• Hysterectomy
• Clitoral release with vaginectomy
• Metoidioplasty
• Phalloplasty
• Testicular implants with scrotoplasty
• Penile implant

Eligibility

Prior to beginning the referral process for transition-related surgeries, the following eligibility criteria must be met: 

• Has a diagnosis of persistent gender dysphoria 
• For breast augmentation surgery: Has completed 12 continuous months of hormone therapy with no breast enlargement (unless hormones are not appropriate for the person)
• For External Genital Surgery Only: Has completed 12 continuous months living as gender(s)

Not Covered

As of right now, OHIP does not cover the following procedures identified as medically necessary by the World Professional Association for Transgender Health:

• Liposuction
• Electrolysis
• Chest contouring/masculinization
• LASER hair removal
• Hair transplants
• Tracheal shave
• Voice modification surgery
• Chin, nose, cheek or buttock implants
• Facial feminization/masculinization

*OHIP does not cover travel costs involved in obtaining surgery. If you are in financial need and must travel to obtain an OHIP approved procedure, Hope Air can provide free air travel and accommodation. You can learn more about this option here.

For an overview of transition-related surgeries, risks, benefits and additional information, review Rainbow Health Ontario’s TRS Summary Sheets here .

The Referral Process

Step 1: Connect with Qualified Providers. 

The MOHLTC requires 2 qualified providers submit a “Request for Prior Approval for Funding of Sex Reassignment Surgery” form (can be found on the “Clinical Resources” section of our resource library ).

Who is a qualified provider? 

The MOHLTC criteria for a qualified provider includes Physicians, Nurse Practitioners, Registered Nurses, Psychologists and Registered Social Workers. Eligible providers are expected to self-assess if providing transition-related surgical referrals is within the scope of their practice. There is no single training course that “qualifies” a provider, but providers are encouraged to undertake professional development and training activities to build their capacity on trans health services.

If your primary care provider is not able to submit a Prior Approval form on your behalf, Centretown Community Health Centre can help.

Step 2: Participate in a Transition-Related Surgery (TRS) Planning Visit

A TRS planning visit is a collaborative visit between a patient and a qualified provider to discuss TRS and how to optimize the patient’s experience and outcome. Topics discussed include reviewing World Professional Association for Transgender Health (WPATH) and MOHLTC criteria, confirming the diagnosis of gender dysphoria, reviewing the stability of medical and mental health conditions, confirming surgery-specific informed consent and planning aftercare.

Step 3:  Complete the Prior Approval Form

Following your Transition-Related Surgery Planning Visit, your provider can complete, sign, and submit the “Request for Prior Approval for Funding of Sex-Reassignment Surgery” (also known as the “Prior Approval” form) to the MOHLTC.

The number of qualified providers who must complete independent TRS surgery planning visits and sign a Prior Approval form is based on the type of surgery requested. 

Upper body surgery requires a TRS planning visit(s) by one qualified provider (either a P hysician or Nurse Practitioner). 

Gonadal or external genital surgery requires independent TRS planning visits with two qualified providers, one of whom must be a Physician or Nurse Practitioner, while the second can be a Physician, Nurse Practitioner, Registered Nurse, Psychologist, or a Registered Social Worker with a Masters of Social Work. 

Once the application is submitted, the MOHLTC will then send a response letter with the outcome of the funding application. 

If approval is not received, your qualified provider can contact the MOHLTC to provide additional information, the application can be resubmitted, and/or an internal review of the initial application can be requested by your provider.

Step 4: TRS Referral Letter Sent to TRS Surgeon 

Once an approval letter is received from the MOHLTC, your provider can send a referral letter to the transition-related surgery surgeon. TRS referral letters are often more in-depth than typical referral notes and often include details about your TRS planning visits. Surgeons will often request additional documentation, including medication lists, lab results and other information.

Step 5: Complete TRS and After Care 

Once referred to a TRS surgeon, you will be contacted by the surgeon or clinic to sort out additional details, and will receive more information as your surgery date nears.

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Gender-affirming surgery.

OHSU surgeons are leaders in gender-diverse care. We provide specialized services tailored to the needs and goals of each patient. We offer:

• Specialists who do hundreds of surgeries a year.
• Plastic surgeons, urologists and other specialists who are leading experts in bottom surgery, top surgery and other gender-affirming options.
• Vocal surgery with a highly trained ear, nose and throat doctor.
• Peer volunteers who can provide support during visits.
• Welcoming care for every patient, every gender and every journey.

Our surgical services

We offer many gender-affirming surgery options for transgender and nonbinary patients, including options within the following types. We also welcome you to request a procedure that isn’t listed on our pages.

Top surgery:

• Gender-affirming mastectomy
• Gender-affirming breast augmentation

Bottom surgery:

• Phalloplasty and metoidioplasty , including vagina-preserving options
• Vaginoplasty and vulvoplasty , including penile-preserving options

Hysterectomy

Nullification surgery, oophorectomy, orchiectomy.

Bottom surgery options also include:

• Scrotectomy
• Scrotoplasty
• Urethroplasty
• Vaginectomy

Additional gender-affirming options:

• Adam’s apple surgery

Vocal surgery

Face and body surgery, preparing for surgery.

Please see our patient guide page to learn about:

• Steps to surgery
• WPATH standards of care
• The letter of support needed for some surgeries

For patients

Request services.

Please fill out an online form:

• I am seeking services for myself.
• I am seeking services for someone else.

Other questions and concerns

Contact us at:

• 503-494-7970
• [email protected]

Refer a patient

• Please complete our  Request for Transgender Health Services referral form   and fax with relevant medical records to  503-346-6854 .
• Learn more on our  For Health Care Professionals  page.

At OHSU, our gynecologic surgeon, Dr. Lishiana Shaffer, specializes in hysterectomies (uterus and cervix removal; often combined with oophorectomy, or ovary removal) for gender-diverse patients. She does more than 150 a year.

We also offer a Transgender Gynecology Clinic with a gender-neutral space. Services include surgery. Referrals and appointments are made through the OHSU Center for Women's Health, though the space is not in the center. Call 503-418-4500 to request an appointment.

Some patients choose hysterectomy to:

• More closely align their bodies with their gender identity.
• With ovary removal, to remove a main source of the hormone estrogen.
• To end pain caused by testosterone therapy that shrinks the uterus.
• To end the need for some gynecologic exams, such Pap smears.

Preparation: We usually recommend a year of hormone therapy first, to shrink the uterus. We don’t require a year of social transition.

How hysterectomy is done

Most often, we use a minimally invasive laparoscope and small incisions in the belly. We usually recommend removing fallopian tubes as well, to greatly reduce the risk of ovarian cancer.

Most patients spend one night in the hospital. Recovery typically takes about two weeks. You’re encouraged to walk during that time but to avoid heavy lifting or strenuous exercise.

Considerations and risks

Hysterectomy is usually safe, and we have a low rate of complications. Risks can include blood clots, infection and scar tissue. Because of a possible link between hysterectomy and higher risk of cardiovascular disease, your doctors may recommend regular tests.

Removing the uterus also ends the ability to carry a child. OHSU fertility experts offer options such as egg freezing before treatment, and connecting patients with a surrogacy service.

OHSU offers nullification surgery to create a gender-neutral look in the groin area.

Nullification surgery may include:

• Removing the penis (penectomy)
• Removing the testicles (orchiectomy)
• Reducing or removing the scrotum (scrotectomy)
• Shortening the urethra
• Removing the uterus (hysterectomy)
• Removing the vagina (vaginectomy)

The procedure takes several hours. Patients can expect to spend one to two nights in the hospital. Recovery typically takes six to eight weeks. Patients are asked to limit walking and to stick to light to moderate activity for four weeks. They should wait three months before bicycling or strenuous activity.

Nullification surgery cannot be reversed. Risks can include:

• Changes in sensation
• Dissatisfaction with the final look
• Healing problems

Removing the penis and testicles or the uterus also affects the ability to conceive a child. OHSU fertility experts offer options such as freezing eggs and connecting patients with a surrogacy service.

Having a gynecologic surgeon remove one or both ovaries is often done at the same time as a hysterectomy. We do nearly all these surgeries with a minimally invasive laparoscope and small incisions in the belly.

Most patients spend one night in the hospital and return to their regular routine in about two weeks.

The ovaries produce estrogen, which helps prevent bone loss and the thickening of arteries. After removal, a patient should be monitored long-term for the risk of osteoporosis and cardiovascular disease.

We encourage patients to keep at least one ovary to preserve fertility without egg freezing. This also preserves some hormone production, which can avoid early menopause.

At OHSU, expert urologists do orchiectomies (testicle removal). Patients may choose this option:

• To remove the body’s source of testosterone
• As part of a vaginoplasty or vulvoplasty (surgeries that create a vagina and/or vulva)
• To relieve dysphoria (some patients choose only this surgery)

Removing the testicles usually means a patient can stop taking a testosterone blocker. Patients may also be able to lower estrogen therapy.

How orchiectomy is done

The surgeon makes an incision in the scrotum. The testicles and the spermatic cord, which supplies blood, are removed. Scrotal skin is removed only if the patient specifically requests it. The skin is used if the patient plans a vaginoplasty or vulvoplasty.

You will probably go home the same day. Patients can typically resume normal activities in a week or two.

Reducing testosterone production may increase the risk of bone loss and cardiovascular disease, so we recommend regular tests. Without prior fertility treatment, orchiectomy also ends the ability to produce children. Serious risks are uncommon but include bleeding, infection, nerve damage and scarring.

Adam’s apple reduction (laryngochrondoplasty)

Dr. Joshua Schindler, an ear, nose and throat doctor who does Adam’s apple and vocal surgeries, completed his training at Johns Hopkins University.

Laryngochrondoplasty is also known as Adam’s apple reduction or a tracheal shave (though the trachea, or windpipe, is not affected).

A surgeon removes thyroid cartilage at the front of the throat to give your neck a smoother appearance. This procedure can often be combined with facial surgery.

Thin incision: At OHSU, this procedure can be done by an ear, nose and throat doctor (otolaryngologist) with detailed knowledge of the neck’s anatomy. The surgeon uses a thin incision, tucked into a neck line or fold. It can also be done by one of our plastic surgeons, typically with other facial surgery.

In an office or an operating room: Our team can do a laryngochrondoplasty in either setting, which may limit a patient’s out-of-pocket expenses.

OHSU also offers Adams’ apple enhancement surgery.

Many patients find that hormone therapy and speech therapy help them achieve a voice that reflects their identity. For others, vocal surgery can be added to raise the voice’s pitch.

Voice therapy: Patients have voice and communication therapy before we consider vocal surgery. Your surgeon and your speech therapist will assess your voice with tests such as videostroboscopy (allowing us to see how your vocal cords work) and acoustic voice analysis.

Effective surgery: We use a surgery called a Wendler glottoplasty. It’s done through the mouth under general anesthesia. The surgeon creates a small controlled scar between the two vocal cords, shortening them to increase tension and raise pitch. Unlike techniques that can lose effectiveness over time, this surgery offers permanent results.

Hormone therapy can bring out desired traits, but it can’t change the underlying structure or remove hair follicles. Our highly trained surgeons and other specialists offer options. Patients usually go home the same day or spend one night in a private room.

Face options:

• Browlift (done with the forehead)
• Cheek augmentation
• Chin surgery (genioplasty), including reductive, implants or bone-cut options
• Eyelid surgery
• Face-lift, neck lift
• Forehead lengthening
• Forehead reduction, including Type 3 sinus setback and orbital remodeling
• Hairline advancement (done with the forehead)
• Jawline contouring
• Lip lift and/or augmentation
• Lipofilling (transferring fat using liposuction and filling)
• Nose job (rhinoplasty)

Body options:

Hormone treatment may not result in fat distribution consistent with your gender. We offer liposuction and fat grafting to reshape areas of the body.

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Gender-Affirming Care

What is gender-affirming care?

Gender-affirming medical care encompasses all our surgical, nonsurgical and mental health care services available to transgender, non-binary and gender non-conforming members of our community. We recognize the specific health needs of LGBTQ+ persons. We’re here to provide the most affirming and reliable health care.

Gender-affirming services and treatments

• Bottom masculinizing and feminizing surgeries
• Chest masculinizing and feminizing surgeries
• Dermatology 
• Facial feminizing surgery
• Hair removal 
• Hormone replacement therapy 
• Mental health services
• Obstetric and gynecologic care and fertility preservation (family planning) 
• Physical therapy
• Primary Care 
• Prosthetics 
• Transition-related medical care
• Voice surgery
• Voice therapy 

Our services are offered in safe and welcoming environments by teams of trusted health professionals. We work together to ensure that your care is coordinated and specific to your needs. Don’t delay — schedule your medical care with Ohio State today.

Why choose Ohio State for gender-affirming care?

The Ohio State Wexner Medical Center is one of only a few academic health centers in the country to offer bottom gender-affirming surgery. Beyond surgical options, we offer the full spectrum of care for our LGBTQ community. We have a dedicated team of medical experts in every field, and through close collaboration aim to serve the LGBTQ population of Columbus and beyond.

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Fact Check: Walz Did NOT Approve Legislation That Overrules Existing Protocols On Age For Gender-Affirming Surgeries

• Aug 9, 2024
• by: Uliana Malashenko

Did Minnesota Gov. Tim Walz sign a bill "allowing gender reassignment surgery for children"? No, that's not true: No state law sets a specific minimum age for gender-affirming surgical interventions, a Minnesota lawmaker told Lead Stories. Major health care providers do not operate on people under 18. One bill signed into law protects youth access to those services discussed in broad terms, but doesn't address a specific age.

The claim reproduced a frequent misconception about gender-affirming care: It ignores that such care is not limited to surgeries and includes many other treatments such as mental health services, puberty blockers and hormone therapies.

The claim appeared in a post (archived here ) on X, formerly known as Twitter, on August 6, 2024, by @BRICSinfo. It said:

Tim Walz, the VP selection for Kamala Harris, signed a bill allowing gender reassignment surgery for children and a bill requiring schools to stock tampons in boys' bathrooms. Donald Trump says he will ban gender reassignment surgery for children in all 50 states.

This is what the post looked like on X at the time of writing:

(Source: X screenshot taken on Wed Aug 7 15:37:05 2024 UTC)

What are the laws?

Rep. Leigh Finke (archived here ) who sponsored several key bills concerning gender-affirming care in Minnesota, told Lead Stories via email on August 8, 2024:

No law in Minnesota has been passed addressing the age of receiving gender affirming care, including surgery. We simply protected access to gender affirming care as it already existed for those who require it ... Standards of care in Minnesota follow the national and international guidelines for gender affirming care. Like all heathcare decisions, gender affirming care is highly personal and individualized. Families, patients, and doctors are best able to make those decisions, not the government. Minnesota's largest providers of gender affirming care do not perform any surgeries on individuals under 18.

Neither legislation about youth transgender health (archived here ), sometimes referred to as the "trans refuge" law (archived here ), nor the Governor's Executive Order on "Protecting and Supporting the Rights of Minnesota's LGBTQIA+ Community Members to Seek and Receive Gender Affirming Health Care Services" (archived here ) contains any provisions overriding existing medical protocols or sets a specific minimum-age bar for what the post called "gender reassignment surgery."

Both pieces of legislation went into effect in 2023. They discuss gender-affirming care in general terms to ensure that those who need care recognized as medically necessary (archived here ) by the Centers for Disease Control and Prevention, can safely access it.

Neither define such care exclusively as surgery. In reality, gender care can be many other things (archived here ). The transgender refuge law doesn't even explicitly mention surgical interventions -- it focuses on mental health services and other aspects of gender-affirming care.

Finke, a member of the Minnesota Democratic-Farmer-Labor Party, added:

In 2024, I carried a bill to require gender affirming care coverage among certain health care plans in the state of Minnesota. This law also did not address standards of care, including age. At no point has Minnesota legislature in the past two years passed legislation to change the standards of gender affirming care--including the age at which surgery could be conducted-- in Minnesota.

In June 2023, the Minnesota Reformer news website reported (archived here ) that "most medical centers require individuals to be at least 18 years old for bottom surgery and chest, or 'top,' surgery."

In the spring of 2024, as Minnesota's gender care legislative actions made the news, Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children's Minnesota, told MPR (archived here ), a local public radio station, that the state does not perform gender-affirming surgeries on patients under 18 years old.

Lead Stories searched Minnesota statutes, laws and rules , but did not find anything that would explicitly set a minimum age for gender-affirming surgeries.

What are the surgeries?

" Gender (or sex) reassignment surgery " (archived here ), as the post on X calls it, is an outdated term (archived here ). It was once used primarily to refer to the medical interventions that change a person's genitalia.

The World Professional Association for Transgender Health (WPATH) manual (archived here ) -- one of the most authoritative sources of evidence-based gender care recommendations -- suggests on page 59 the term "gender-affirming surgeries," instead, . The current term incorporates several more interventions, and not all of them concern genitalia or the chest area, according to the appendix , attached to Chapter 13.

The newer term and its definition are consistent with the wording used by Minnesota's Department of Human Services (archived here ).

Who counts as a child?

In Minnesota, a child, or a minor, is any person younger than 18 (archived here ). After that, a person is generally considered an adult for many legal purposes. Though certain restrictions are still applicable (archived here ), that does not include required parental consent when it comes to health care (archived here ).

For gender-affirming care, however, "child" is not a blanket term for anyone under 18: People go through several developmental stages between birth and adulthood, and health care professionals consider that while deciding what is appropriate and medically necessary.

For example, the WPATH guidelines (archived here ) differentiates between children, pubescent youth and adults, as seen on page 67:

Unlike pubescent youth and adults, prepubescent gender diverse children are not eligible to access medical intervention (Pediatric Endocrine Society, 2020); therefore, when professional input is sought, it is most likely to be from an HCP [health care professional] specialized in psychosocial supports and gender development.

While WPATH suggests that there might be some benefits if vaginoplasty is performed before the age of 18, that appears to offer some flexibility -- not a blanket recommendation. At the same time, the organization still strongly advises against phalloplasty before that age.

The Minnesota Department Human Services (archived here ) prohibits one particular surgery -- phalloplasty -- before 18. In any case, the agency requires authorization for any other gender-affirming surgery, listing additional requirements for those younger than that age.

Trans youth and genital surgeries

Lead Stories was not able to locate any Minnesota-specific data about gender-affirming surgeries performed on people under 18, but available national statistics confirmed that genital surgeries in that age category are incredibly rare.

For example, a 2022 Reuters story (archived here ), citing an analysis of insurance claims for roughly 330 million U.S patients over five years, reported that:

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021.

A 2023 study (archived here ) published by the American Medical Association's JAMA Network Open, a peer-reviewed medical journal, read:

... breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

A 2024 article in JAMA Network Open (archived here ) found that among minors who had gender-affirming surgeries in 2019, 96.4 percent -- or 82 out of 85 cases -- were chest-related procedures, not genital surgeries.

Lead Stories contacted Minnesota Gov. Walz about the claim that is the target of this fact check. If we get a response, the article will be updated as appropriate.

About @BRICKinfo

The same account on X that posted the claim that is the focus of this fact check previously published a misleading statement about President Joe Biden before he dropped out of the presidential race. Lead Stories debunked it here .

Further reading

Lead Stories previously debunked false claims about transitions in toddlers here . Other Lead Stories fact checks concerning claims about transgender issues can be found here . Fact checks of claims about the 2024 U.S. presidential election are here .

Uliana Malashenko is a  New York-based freelance writer and fact checker. Read more about or contact Uliana Malashenko

Lead Stories is a fact checking website that is always looking for the latest false, misleading, deceptive or inaccurate stories, videos or images going viral on the internet. Spotted something? Let us know! .

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Fact Check: Satirical Claim Falsely Says Hope Walz Received $82,000 In Student Loan Forgiveness, Parents Worth $138 Million

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• Open access
• Published: 10 August 2024

Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran

• Elham Rahimpour 1 ,
• Elham Askary 1   nAff4 ,
• Shaghayegh Moradi Alamdarloo 1 ,
• Saeed Alborzi 2 &
• Tahereh Poordast 3  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  100 ( 2024 ) Cite this article

120 Accesses

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Gender dysphoria, characterized by a misalignment between one’s gender identity and assigned sex, propels individuals towards medical interventions like gender reassignment surgery (GRS) to harmonize their bodies with their gender. This process aims to enhance overall quality of life (QoL), functioning, and body image. Recognizing the importance of cultivating a positive body image for transgender individuals navigating societal norms, this narrative highlights the ongoing debate surrounding QoL post-GRS. In response, our study is outlined, aiming to scrutinize QoL and self-image among transgender men post-GRS, offering valuable insights into societal perceptions and psychological well-being in this context.

This cross-sectional survey focused on transgender men aged 15 to 35 who underwent gender reassignment surgery (GRS) in 2018–2022 in Shiraz, Iran. Participants, after passing psychiatric evaluations, completed World Health Organization Quality of Life (WHOQOL-100) questionnaires pre- and at least one-year post-surgery. The scores of the Brief-WHOQOL questionnaire were evaluated in four domains of physical health, psychological health, social relationships, and environmental health.

A total of 60 individual who underwent GRS completed our questionnaire. The average age of the patients was 24.1 ± 3.8 years. Following GRS, the most increase was observed in the psychological factor (by 25.6%). The increase in score was statistically significant in all subgroups ( P  < 0.001) after operation. Urban living location had a significant association with higher increase in physical health ( P  < 0.010), psychological health ( P  = 0.005), and environmental health ( P  = 0.012) after GRS. In regards to physical health, the low socioeconomic group had a significantly less physical score improvement in QoL compared to the moderate group ( P  = 0.024) following GRS. In regards to environmental health, the high socioeconomic groups had significantly higher improvement in QoL compared to the low ( P  = 0.006) and moderate ( P  < 0.001) group after operation.

The results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients hailing from low socioeconomic backgrounds and rural areas.

Gender dysphoria is a is described as a persistent and distressing misalignment between gender identity and the sex assigned at birth [ 1 ]. To alleviate the physical incongruence and distress associated with gender dysphoria, there is often a strong desire for medical and surgical interventions to align the body more closely with one’s experienced gender [ 2 ]. The prevalence of gender dysphoria seems to be increasing globally [ 3 , 4 , 5 ].

Transgender individuals often experience a sense of being trapped in the wrong gendered body and typically seek hormonal and surgical reassignment to align with their identified gender. Many desire the removal of the uterus and ovaries promptly to alleviate the stress of menstrual occurrences and reduce estrogen production, facilitating the effectiveness of exogenous androgen therapy [ 6 ].

Quality of life (QoL) is characterized as an “individuals’ perceptions of their position in life concerning their goals, expectations, standards, and concerns in the context of the culture and value systems in which they live.” This encompasses a broad concept influenced by factors such as physical health, psychological well-being, level of independence, social relationships, personal beliefs, and the connection to significant aspects of their environment. The intricate interplay of these elements contributes to the overall understanding of an individual’s quality of life. [ 7 , 8 , 9 , 10 ]

Gender reassignment surgery (GRS) is widely acknowledged for enabling transgender individuals to embrace their identified gender fully, marking it as the most effective treatment option [ 11 ]. Both GRS and hormonal treatment (HT) have demonstrated enhancements in quality of life (QoL), overall functioning, and body image perception. Despite variations in hormonal treatment dosages in some studies and the absence of standardized assessments for hormonal status, positive effects have been observed. Additionally, some experts suggest that GRS and HT might contribute to a reduction in the risk of suicidal attempts among transgender individuals [ 11 , 12 , 13 , 14 ].

Transgender individuals should have the opportunity to cultivate a positive body image [ 15 ]. For transgender people, body image serves as a means of self-expression and enables them to navigate their transgender identity in a world that often perceives gender in binary terms. This dynamic gives rise to a complex interplay of desire, authenticity, and the need to avoid societal stigma. Achieving a positive body image is crucial for trans people as it empowers them to assert their identity and cope with the challenges posed by societal norms and expectations. [ 16 ]

There exists a lack of consensus in the field regarding QoL, particularly post-gender reassignment surgery [ 17 ]. Some earlier studies indicate that transgender individuals exhibit lower QoL compared to the general population [ 17 , 18 , 19 ], while others report no significant differences in QoL or psychological functioning between transgender individuals and the general population [ 14 , 20 , 21 , 22 ]. Poor sexual life quality post-surgery can negatively impact psychological well-being, causing considerable distress [ 23 ]. Thus, this study seeks to assess the quality of life and self-image among transgender men following gender reassignment surgery (GRS), aiming to contribute valuable insights to the ongoing discourse in this area.

Homosexuality is banned in Iran, but gender reassignment (GR) has been religiously permitted since 1987 after the Iranian revolution. Iran stands as the sole Islamic nation endorsing and financially supporting GRS procedures. As per the Family Protection Law since 2012, any individual in Iran may submit their request for gender matching to the family court there. According to Ahmadzadeh’s study between 2002 and 2009, the annual application rate for transgender women was approximately 1 in 145,000, and for transgender men was around 1 in 136,000. In 2022, this figure was accompanied by a two-fold increase in requests by transgender men compared to transgender women, highlighting the increasing prevalence of gender reassignment in Iran. [ 24 , 25 ].

This study marks a significant milestone as it is the first of its kind conducted among Iranians, shedding light on the quality of life and self-image among transgender men post-GRS. It is noteworthy to mention that this research highlights the cultural and religious context that is still evolving, with acceptance by families being a recent development and societal integration still in progress. The strengths of this study lie in its comprehensive examination of various aspects related to transgender healthcare within an Iranian cultural framework, offering valuable insights into the experiences of transgender individuals in a society where such topics are relatively emerging.

Material and method

In this cross-sectional survey study, we included transgender men participants who underwent GRS between 2018 and 2022 (4 years) at Shahid Faghihi, Zeinabiyyeh, Peyvand, Ali-Asghar and Madar-kodak Hospitals, the five major hospitals affiliated with Shiraz University of Medical Sciences in Shiraz, Iran. GRS was performed among the participants through the laparoscopic hysterectomy and bilateral salpingo -oophrectomy method. All participants underwent a psychiatric evaluation to ensure the absence of severe psychiatric disorders, excluding any lifetime history of organic mental disorders, mental retardation, psychotic disorders, bipolar disorders, substance abuse, and severe Axis II psychopathology (cluster A personality disorder, antisocial personality disorder, and borderline personality disorder) according to the DSM-V [ 26 ].

Before undergoing surgery to remove the uterus and ovaries, individuals had already undergone mastectomy and were living with a man. A new birth certificate will be issued to them immediately following the hysterectomy. Patients often avoided discussing surgery related to external genitalia, despite it being a crucial aspect of the GRS. This could be due to the fact that, talking about genitalia in Iran is culturally sensitive, leading to reliance on non-verbal cues for sexual communication and seeking satisfaction in sexual roles.

The questionnaires were administered twice during the study period, once before the surgery and once at least one year after undergoing GRS. patients were contacted through a telephone survey, and after explaining the aim and details of the study, they provided verbal informed consent. All patients agreed to the participation in the study, sharing and publishing their information and questionnaires.

We utilized the Persian version of the WHOQOL-BREF questionnaire for the purpose of our study [ 27 , 28 ]. The WHOQOL-BREF is a 26-item tool with four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), including QOL and general health items. Each item is rated on a five-point ordinal scale (1 to 5), and scores are linearly transformed to a 0–100 scale [ 29 , 30 ]. In the physical health domain, items assess mobility, daily activities, functional capacity, energy, pain, and sleep. The psychological domain covers self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory concentration, religion, and mental status. Social relationships involve personal relationships, social support, and sex life. The environmental health domain addresses financial resources, safety, health and social services, living physical environment, opportunities for skills and knowledge, recreation, general environment (noise, air pollution, etc.), and transportation. Cultural differences do not influence the importance of the domains. The scores ranged from 1 to 5 for each question, and ranged from 7 to 35 for physical health, 6 to 30 for psychological health, 3 to 15 for social relationships, and 8 to 40 for and environmental health (8 items).

The questionnaire has been translated and validated in Persian language [ 27 ]. Subjects rate each item on a Likert scale ranging from 1 to 4 or 1 to 5 [ 31 ]. We also added two extra questions of “Do you have any issues in your sexual life” and “To what extent are your sexual needs met?”. The answers consisted of “not at all/very poor/ very dissatisfied/ never as 0, not much/poor/ dissatisfied/seldom as 1, moderately/neither poor nor good/ neither satisfied nor dissatisfied/ quit often as 2, a great deal/good/ satisfied / very often as 3, and completely/very good/ very satisfied/ an extreme amount/ always as 4. Score calculation was performed according to the WHOQOL manual [ 28 ].

All analyses were performed using the Statistical Package for Social Science (SPSS v.27.0 software). Distribution was summarized through means and standard deviations (mean ± SD) or median and interquartile range (IQR). Descriptive statistics are reported as frequency and percentage (%). Wilcoxon signed test was applied to evaluate differences between the responses before and after surgery. Statistical significance was accepted at the two-tailed P  < 0.05 significance level.

A total of 60 transgender men individual who underwent GRS completed our questionnaire. The average age of the patients before operation was 24.1 (SD: 3.8; range: 13–31). Table  1 demonstrated the demographic features of the patients in our study. None of our participants were married.

The participants filled out the Brief-WHOQOL questionnaire at two phases of before operation and after operation. The median interval between the filling of questionnaire was 3 years. The descriptive frequency of the responses in our study is demonstrated in Table  2 .

As shown in Table  2 , and accounting for reverse scoring in several questions (F1.4, F11.3, F8.1, and Extra 1), the responses demonstrated overall improvement in all questions. The increase was significant in all questions following GRS ( P  < 0.05) except three questions: “Have you enough money to meet your needs?”, “How available to you is the information that you need in your day-to-day life?”, and “How satisfied are you with the support you get from your friends?”. The highest improvement was in the question “Are you able to accept your bodily appearance?” by 113%.

The scores were evaluated in four domains of physical health, psychological health, social relationships, and environmental health. Figure  1 demonstrates the average score of the participants before and after surgery. The most increase was observed in the psychological factor (by 25.6%), followed by physical health (19.1%), social relationships (13.2%), and environmental health (10.9%). The increase in score was statistically significant in all subgroups ( P  < 0.001).

Quality of life subsection score before and after surgery

When evaluating the amount of change in the subgroups, based on the participants demographic features, we observed no significant association with age, marital status, or educational level. Living location had a significant association with physical health ( P  < 0.010), psychological health ( P  = 0.005), and environmental health ( P  = 0.012), but not social relationships ( P  = 0.088), with urban residents demonstrating higher level of change. The socioeconomic status of the participants also had a significant association with physical health ( P  = 0.023) and environmental health ( P  < 0.001), but not psychological health ( P  = 0.596) or social relationships ( P  = 0.684). Based on the post-hoc test results, in regards to physical health, the low socioeconomic group had a significant lower physical score compared to the moderate group ( P  = 0.024), however, there was no significant difference between the moderate and high group ( P  = 1.000) or the low and high group ( P  = 0.070). In regards to environmental health, the high socioeconomic groups had significantly higher improvement compared to the low ( P  = 0.006) and moderate ( P  < 0.001) group.

A total of 60 transgender men who underwent GRS completed our questionnaire. The average age of the patients before operation was 24.1, which was lower to similar studies [ 20 , 32 ]. The majority of participants were educated, which is in accordance to a previous study by Cardoso da Silva et al. [ 32 ]. Most participants resided in urban areas (61.7%) and had a moderate (50%) or high (30%) socioeconomic status. Our results indicated an increase in QoL after GRS, which is line with previous reports [ 32 , 33 ]. Dhiordan et al. conducted a pre-post survey assessing GRS impact on transgender women in Brazil. Their findings revealed improvements in the psychological social relationships of the WHOQoL-BREF after stereotactic radiosurgery when comparing post-surgery results to pre-surgery evaluations [ 32 ]. We observed that the QoL significantly increased, both in overall scores and also in subgroups of physical, psychological, social, and environmental health. These changes were unrelated to patients age, marital status, and education, and more influenced by their socioeconomic status and living location. This demonstrates the importance of the environment and living situation and culture which can influence the individuals’ beliefs and QoL. The patients with a low socioeconomic status demonstrated the lowest change in their physical and environmental health factors. On the other hand, patients with high socioeconomic status demonstrated significant improvement in their environmental health. Also, urban living residents compared to rural residents showed significantly higher improvement in physical, psychological, and environmental health factors. Our study is the first of its kind conducted in Iran, offering a groundbreaking exploration into the quality of life and self-image of transgender men post-GRS within the Iranian context. By comprehensively examining various aspects of their experiences, this study fills a crucial gap in existing research and provides valuable insights into the challenges and successes faced by transgender individuals in Iran. Additionally, its thorough investigation contributes to the advancement of knowledge and understanding in both academic and clinical settings, paving the way for further research and improved support for transgender individuals in Iran and beyond.

In a more detailed evaluation of the responses, the increase in QoL was significant in all questions except three questions: “Have you enough money to meet your needs?”, “How available to you is the information that you need in your day-to-day life?”, and “How satisfied are you with the support you get from your friends?”. These questions represent the socioeconomic status, availability of information, and social support of the participants, respectively. The observable traits of transgender individuals, such as their voice and facial features, along with the behaviors of their friends and family, plays a crucial role in their post-surgery interactions within the community. Transgender women were identified to experience greater limitations and challenges in this regard [ 34 ]. Factors like disapproval from family and the community may expose transgender individuals to vulnerability, gradually influencing their QoL and potentially contributing to the onset of depression [ 35 ]. Rezaei et al. demonstrated that aspects such as family function, emotional fusion, behavior control, and emotional responsiveness can play a crucial role in facilitating the acceptance of their new sexual role among transgender individuals [ 36 ].

Engaging in a range of social activities due to gender reassignment has been observed to enhance the sociability and activity levels of transgender individuals, fostering stronger social connections and helping them overcome social isolation. This enhancement in social relationships has the potential to elevate their overall QoL [ 37 , 38 ].

A notable aspect of focus in this study is sexual activity, which showed improvement after GRS through the two additional questions we provided. This finding has also been supported in previous studies [ 32 ]. One potential explanation for this observation could be linked to a heightened sense of personal fulfillment post-surgery and an enhanced acceptance of one’s body. This is also evident in our study, which the highest improvement was in the question “Are you able to accept your bodily appearance?” by 113%. Bartolucci et al. [ 23 ] asserted that GRS serves as a cornerstone for individuals with gender dysphoria, not only addressing their gender dysphoria but also leading to an enhancement in sexual satisfaction.

This study has various limitations, notably the short-term evaluation period post-GRS, the varying recovery times of patients after surgery, and the diverse levels of QoL among individuals. Consequently, we underscore the importance of conducting additional follow-up trials to comprehensively assess satisfaction with GRS.

Our study stands as one of the initial reports to assess the outcomes of surgical interventions in transgender individuals in Iran. Additionally, it adds value to the limited body of literature by employing the WHOQOL-BRIEF instrument both before and after GRS. The results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients from low socioeconomic backgrounds and rural areas. Therefore, an increase in targeted support and resources for individuals from these demographics is warranted.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request and with permission of the Research Ethics Committee of the Shiraz University of Medical Sciences.

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Elham Askary

Present address: Obstetrics and Gynecology Office, Shahid Faghihi Hospital, Zand Avenue, Shiraz, 7134844119, Iran

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Department of Obstetrics and Gynecology, School of Medicine, Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Elham Rahimpour, Elham Askary & Shaghayegh Moradi Alamdarloo

Department of Obstetrics and Gynecology, School of Medicine, Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Saeed Alborzi

Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

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T P, E A, E R, Sh M and S A designed the study. E R collected the data; E R analyzed the data; E A and E R interpreted the results; E A, Sh M and T P conceived and designed the study. E A, E R and Sh M wrote the manuscript. All authors discussed the results and revised the manuscript. All authors read and approved the final manuscript.

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Rahimpour, E., Askary, E., Alamdarloo, S.M. et al. Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran. Child Adolesc Psychiatry Ment Health 18 , 100 (2024). https://doi.org/10.1186/s13034-024-00794-0

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Lydia Polgreen

The Strange Report Fueling the War on Trans Kids

By Lydia Polgreen

Opinion Columnist

I n its upcoming term, the Supreme Court will once again hear a case that involves a highly contentious question that lies at the heart of personal liberty: Who should decide what medical care a person receives? Should it be patients and their families, supported by doctors and other clinicians, using guidelines developed by the leading experts in the field based on the most current scientific knowledge and treatment practice? Or does the Constitution permit lawmakers to place themselves, and courts, in the middle of some of the most complex and intimate decisions people will make in their lives?

The case, United States v. Skrmetti , has been brought by the Biden administration to challenge a ban in Tennessee on gender-affirming care for adolescents that all major American medical organizations support. Tennessee is one of some two dozen states that have passed laws limiting gender-affirming care for young people. The appeal argues that these bans are an unconstitutional form of sex discrimination: They forbid long-used treatments for transgender adolescents that are also given to children who are not transgender for different reasons.

The Tennessee law, called the Protecting Children From Gender Mutilation Act, prohibits the use of puberty-blocking medications for transgender adolescents, for example, but permits them for children who go into puberty at an early age. It bans the use of sex hormones like testosterone in transgender adolescents but allows it for other health issues, such as for children assigned male at birth. It bans gender-affirming surgeries for transgender adolescents — such surgeries are extremely rare — but allows similar surgical procedures that affirm the sex a child is assigned at birth, even on infants who are intersex.

The Supreme Court ruled in 2020 — somewhat surprisingly given its conservative majority — that differential treatment of transgender and gay people is impermissible under civil rights law. “It is impossible,” Justice Neil Gorsuch wrote in his decision in that landmark employment discrimination case, “to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Lawyers seeking to overturn gender-affirming-care bans will urge the court to follow the logic of that ruling and declare the Tennessee law and others like it unconstitutional.

Lawyers arguing in favor of these bans have taken a sharply different approach. In a striking echo of the arguments used to challenge medical abortion, they have asserted , against the consensus of the mainstream medical science, that the standard treatments for transgender children are not based in evidence and represent a grave risk to the health and well-being of young people.

This argument has been floating around conservative circles in the United States for some time, and some European government health care systems have embraced it, too, with some limiting access to gender-affirming care for young people, citing doubts about the evidence supporting it. The argument has been supercharged in recent months by an unlikely ally on the other side of the Atlantic Ocean: the British pediatrician Hilary Cass.

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Ohioans aren't reflected in current districts. Gerrymandering ballot issue must pass

Thomas Suddes is a former legislative reporter with the Plain Dealer in Cleveland and writes from Ohio University. [email protected]

A ruling last week by a Republican judge demonstrates why Ohioans should approve this November’s “ Citizens Not Politicians” ballot issue to end the gerrymandering of General Assembly and congressional districts.

At issue: A bid by opponents to overturn Republican state legislators’ latest foray into bashing trans-sexual Ohioans, Substitute House Bill 68 , passed in January, overriding its veto by Republican Gov. Mike DeWine.

DeWine is wrong about gerrymandering: Why Gov. Mike DeWine is wrong about gerrymandering yet again

Voting to override were all Republican General Assembly members present except Sen. Nathan Manning, of North Ridgeville. Also opposing the override were all House- and Senate Democrats present.

HB 68’s key points:

• It forbids physicians from providing a minor with gender reassignment surgery.
• And amid a blizzard of legalese, forbids overseers of interscholastic athletics to let male athletes participate in female athletic competitions.

If you’re wondering why General Assembly Republicans (26 of 33 senators, 67 of 99 representatives) are trying to simultaneously play family doctor and Friday night ref, the reason is demagoguery.

It’s trickier than it used to be for cheap-shot politicians to beat up on non-white Americans and on women. But these days, at least in Ohio, bashing sexual and gender minorities can be just the ticket — even with legislation such as HB 68, so ill-fashioned that even DeWine, a lifelong, pro-family conservative, wouldn’t sign it.

Trans youth in GOP's crosshair

The American Civil Liberties Union , its Ohio unit, and the Boston-based law firm Goodwin Procter sued in Franklin County Common Pleas Court on behalf of two transgender adolescents and their families to overturn HB 68 on a range of grounds, in part because of the bill’s alleged violation of the Ohio Constitution one-subject rule.

The one-subject rule, part of the constitution since 1851, is aimed against “logrolling,” which the Legislative Service Commission describes as “the combination of unrelated bills into an omnibus bill to secure ‘a degree of support for the measure which it might not have enjoyed on its own merits,’ citing a 1983 study by historian David E. Bowers.

Last week, Franklin County Common Pleas Judge Michael J. Holbrook , a Republican, in summarizing a central issue in the lawsuit, wrote that the “plaintiffs will have to leave ... Ohio to seek gender affirming care if [HB 68] is enforced ... and therefore will be adversely affected by its enforcement.” But Holbrook rejected the challenge to House Bill 68, allowing it to take effect.

Twice tucked into the judge’s ruling are ironic passages that illustrate one futility in today’s Ohio politics. Rejecting arguments that HB 68 it violates the constitution’s one-subject rule — by melding transgender care and athletic regulation — Holbrook wrote that those merging this topics forms “a ‘legitimate subject’ for purposes of the single subject rule ... the recourse for those who object is not within the court but is instead with their vote.

Ohio voters aren’t treated equally

Likewise, in rejecting arguments other parts of HB 68 also breached the one-subject rule, “Recourse for those who are dissatisfied with the General Assembly’s determinations [about proper observance of the one-subject rule] must be exercised through their vote as opposed to the judicial system.

Keen advice, your honor — except for the fact that, thanks to gerrymandering, all Ohio voters aren’t treated equally. As Ohio now operates, General Assembly districts were drawn by and for Republicans. That means a state that twice voted for Bill Clinton and twice for Barack Obama has a legislature that is overwhelmingly Republican — and toils to make Ohio a backwater and sometimes a laughingstock.

Ballot issue promises hope for Ohio: Ohioans will have a chance to regain power seized by lawmakers

In November, Ohioans will have the chance to ensure fairly drawn General Assembly districts by voting for the “Citizens Not Politicians” ballot issue, proposed by petition, which would empower a citizens redistricting commission, that excludes politicians, to draw fair legislative and congressional districts.

No way should today’s Ohio, which cast 51% of its vote for Donald Trump in 2016 , 53% in 2020 , have a House that’s 68% Republican and a Senate that’s 79% GOP.

Plainly stated, last week’s ruling — that only voters, not courts, may curb the General Assembly’s antics — describes an Ohio that, without ratification of November's Issue 1 , doesn’t exist.

Thomas Suddes is a former legislative reporter with the Plain Dealer in Cleveland and writes from Ohio University. [email protected] .