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An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960-2010: Prevalence, Incidence, and Regrets


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Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications 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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An Analysis of All Applications for Sex Reassignment Surgery
in Sweden, 1960–2010: Prevalence, Incidence, and Regrets
Cecilia Dhejne Katarina O
¨berg Stefan Arver
Mikael Lande
Received: 8 October 2013 / Revised: 11 December 2013 / Accepted: 14 December 2013
Springer Science+Business Media New York 2014
Abstract Incidence and prevalence of applications in Sweden
for legal and surgical sex reassignment were examined over a
50-year period (1960–2010), including the legal and surgical
reversal applications. A total of 767 people (289 natal females
and 478 natal males) applied for legal and surgical sex reas-
signment. Out of these, 89 % (252 female-to-males [ FM] and 429
male-to-females [MF]) received a new legal gender and under-
went sex reassignment surgery (SRS). A total of 25 individuals (7
natal females and 18 natal males), equaling 3.3 %, were denied a
new legal gender and SRS. The remaining withdrew their
application, were on a waiting list for surgery, or were granted
partial treatment. The incidence of applications was calculated
and stratified over four periods between 1972 and 2010. The
incidence increased significantly from 0.16 to 0.42/100,000/year
(FM) and from 0.23 to 0.73/100,000/year (MF). The most pro-
nounced increase occurred after 2000. The proportion of FM
individuals 30 years or older at the time of application remained
stable around 30 %. In contrast, the proportion of MF individuals
30 years or older increased from 37 % in the first decade to 60 %
in the latter three decades. The point prevalence at December
2010 for individuals who applied for a new legal gender was for
FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctu-
ated but was 1:1.66 for the whole study period. There were 15 (5
MF and 10 MF) regret applications corresponding to a 2.2%
regret rate for both sexes. There was a significant decline of
regrets over the time period.
Keywords Transsexualism Gender identity disorder
Gender dysphoria Incidence Prevalence Sex ratio
Gender identity denotes the personal sense of being a female or
male. Gender dysphoria denotes the distress caused by a dis-
crepancy between the gender identity and a person’s sexassigned
at birth. For some people, the level of distress meets criteria for a
formal diagnosis of Transsexualism according to ICD-10,
Transsexualism according to DSM-III and DSM-III-R, Gender
Identity Disorder according to the DSM-IV and DSM-IV-TR, or
Gender Dysphoria according to the DSM-5 (American Psychi-
atric Association, 1980,1987,1994,2000,2013; World Health
Organization, 1992). The clinical presentation generally
includes discomfort with natal sex characteristics and a request
for medical help to alter the phenotypic expression of the body.
Requests may include treatment with contrary sex hormones,
hair removal in natal males, surgery to aid changes of primary
and secondary sex characteristics, and a new legal gender.
C. Dhejne
Center for Psychiatric Research, Department of Clinical
Neuroscience, Karolinska Institutet, Stockholm, Sweden
C. Dhejne (&)K. O
¨berg S. Arver
Center for Andrology and Sexual Medicine, C2:84, Karolinska
University Hospital, 141 86 Stockholm, Sweden
K. O
¨berg S. Arver
Department of Medicine/Huddinge, Karolinska Institutet,
Stockholm, Sweden
M. Lande
Institute of Neuroscience and Physiology, Sahlgrenska University
Hospital, Gothenburg, Sweden
M. Lande
Department of Medical Epidemiology and Biostatistics,
Karolinska Institutet, Stockholm, Sweden
Arch Sex Behav
DOI 10.1007/s10508-014-0300-8
Epidemiological studies on incidence, prevalence, and sex
ratio of transsexualism are usually based on indirect calcula-
tions, for example the number of individuals in a specified
catchment area (a whole country or part of a country) who apply
for sex reassignment at gender clinics, who receive a diagnosis
of transsexualism, who start sex reassignment treatment, and/or
apply for legal gender recognition (Zucker & Lawrence, 2009).
Most but not all incidence and prevalence estimates have been
based on the population over 15 years of age. Legal sex reas-
signment is in most countries not allowed before the legal age,
which is 18 years in most countries. Germany is an exception
with no lower age limit.
Table 1summarizes the reported prevalence, incidence, and
sex ratio in different regions. Prevalence figures range from
1:8,300–1:400,000 for female-to-males (FM) and 1:2,900–
1:100,000 for male-to-females (MF). Incidence figures for
diagnosed transsexualism are available from Australia, Cata-
lonia, Denmark, England and Wales, Germany, and Sweden and
vary from 0.15 to 0.73 per 100,000 per year for both genders
´mez-Giletal.,2006; Hoenig & Kenna, 1974;Lande
˚linder, & Lundstro
¨m, 1996; Meyer zu Hoberge, 2009;Ols-
son & Mo
¨ller, 2003;Ross,Wa
˚linder, Lundstro
¨m, & Thuwe,
˚linder, 1971; Weitze &
Osburg, 1996). There is a dearth of studies assessing incidence
rates over time in adults. In Sweden, the incidence rate of
applications for sex reassignment surgery (SRS) increased from
0.17/100,000/year between 1972 and 1992 to 0.24/100,000/y ear
between 1992 and 2002 (Lande
2003). Anecdotal evidence suggests that this trend has accel-
erated after 2002. In Canada, a sharp increase was reported in
referrals of adolescents with gender dysphoria between the
periods 2000–2003 and 2008–2011 (Wood et al., 2013). Similar
data for adolescents have been reported from Amsterdam’s
clinic for adolescents (de Vries & Cohen-Kettenis, 2012).
As can be seen in Table 1, the sex ratio (here reported as
FM:MF ratio) differs across studies, clinics, and countries. Some
have found an excess of MF, for example 1:6 in New Zeeland
(Veale, 2008), 1:6.1 in Australia (Ross et al., 1981),1:3inSin-
gapore (Tsoi, 1988), and 1:2.6 in Catalonia (Go
´mez-Gil et al.,
2006). Other have showed a more equal sex ratio such as 1.3:1 in
Hamburg, Germany, 1.1:1 in Oslo, Norway (Kreukels et al.,
2010), and 1:1 in Finland (Pimenoff, 2006) whereas Japan and
Poland have reported an excess of FM, 2:1 and 3.4:1, respec-
tively (Baba et al., 2011; Dulko & Imielinski, 2004). A trend
towards a more equal sex distribution over time has been dem-
onstrated in Germany, from 1:2.3 (1981–1990) to 1:1.5 (1991–
2000) (Meyer zu Hoberge, 2009; Weitze & Osburg, 1996).
Likewise, the sex ratio in Serbia has gone from 1:2 in 1987 to 1:1
in 2007 (Vujovic, Popovic, Sbutega-Milosevic, Djordjevic, &
Gooren, 2008). Sweden went in the opposite direction from 1:1.4
in 1972 to 1:1.8 in 2002 (Olsson & Mo
¨ller, 2003).
Sweden is uniquely positioned to assess trends in appli-
cations for gender reassignment/confirmation at a national
level as every person requesting a legal sex change and a genital
surgical procedure must apply to the Legal Board of the National
Board of Health and Welfare. The aims of this study were to
investigate incidence trends and prevalence for persons apply-
ing for a new legal gender and SRS, as well as the number of
applications for reversal to the original sex. We also examined
changes over time with respect to sex ratio, applicants’ age,
average time elapsed from first visit to being granted a new legal
gender, reasons for application rejection, and numbers of indi-
viduals choosing surgical treatment abroad.
The Swedish Procedure for Sex Reassignment
A law regulating surgical and legal sex reassignment in Sweden
came into force in 1972. The law was updated on January 1,
2013. During the period examined, the law stated that if the
person since youth had felt that she/he belongs to a sex other
than that recorded on the birth certificate, had lived for a con-
siderable time in accordance with this new gender role, and is
anticipated to continue to live in such a gender role, the person
could obtain permission for surgical and legal sex reassign-
ment. Gradual changes in praxis have for the last 30 years
enable late onset gender dysphoric individuals to be included.
The person must be at least 18 years old, a Swedish citizen,
unmarried, and sterile. As of January 1, 2013, the prerequisite of
being unmarried was removed and it is now sufficient to have
permanent residency in Sweden. As of July 1, 2013, the pre-
requisite of being sterile was removed.
Figure 1illustrates the flow described below. Individuals
presenting with gender dysphoria in Sweden are referred to one
of six specialized gender teams that adhere to a national con-
sensus program regulating evaluation and treatment. This
national consensus program includes approximately 1 year of
evaluation. Individuals diagnosed with transsexualism then
start gender confirmation treatment, including cross-sex hor-
mones along with real life experience. FMs also may undergo
bilateral mastectomy with chest contouring. MFs receive hair
removal, and speech therapy. Adolescents are treated as adults
although they cannot receive permission for genital surgery a nd
a new legal gender before 18 years of age.
After a minimum of 2 years of evaluation and treatment, the
person can apply to the Legal Board of the National Board of
Health and Welfare in order to receive permission for SRS and a
change of legal sex status. A medical certificate based on the
evaluation describing the gender dysphoria, the diagnosis of
transsexualism, and other potential health problems accompa-
nies the application. Until 1990, it was common with a two-step
procedure where the initial application was for name change and
sterilization. The second application was for final permission to
undergo surgical and legal gender reassignment. All application
Arch Sex Behav
Table 1 Incidence, prevalence, and sex ratio of transsexualism in different countries
Author Country Year or time
Population Prevalence and incidence
calculations based on
Sørensen and Hertoft (1982) Denmark 1951–1981 x x x 1:3.6 Surgical and legal sex reassigned
15 years and older
Hoenig and Kenna (1974) England and
1958–1968 0.17–0.26 total 1:108,000 1:34,000 1:2.9 Referral to a clinic and diagnosed,
according to Wa
˚linder (1968)
15 years and older
˚linder (1968) Sweden 1965–1967 x 1:103,000 1:37,000 1:2.5 Application to a clinic and diagnosed
according to Wa
˚linder (1968)
15 years and older
˚linder (1971) Sweden 1967–1970 0.15 total x x 1:1 Application to a clinic and diagnosed
according to Wa
˚linder (1968)
15 years and older
Dixen, Maddever, Van
Maasdam, and Edwards (1984)
USA ca. 1967–1979 x x x 1:1.7 Applicants for sex reassignment 15 years and older
Pauly (1968) USA 1968 x 1:400,000 1:100,000 1:4 Applying for treatment and diagnosed
with transsexualism
Total population
O’Gorman (1982) Northern-Ireland ca. 1968–1981 x 1:100,000 1:35,000 1:3 Diagnosed with transsexualism Total population
Sørensen and Hertoft (1980) Denmark 1970–1977 0.21 total
0.11 FM
0.31 MF
x x 1:2.8 Applicants for sex reassignment 15 years and older
Garrels et al. (2000) Germany 1970–1998 x x x 1:1.9 Diagnosed with transsexualism at clinics Not stated
´n, Wa
and Lundstro
¨m, (1996)
Sweden 1972–1992 0.17 total x x 1:1.4 Applications to court for legal and surgical
sex reassignment
15 years and older
Godlewski (1988) Cracow, Poland 1974–1980 x x x 5.5:1 Diagnosed with transsexualism (DSM-III) Not stated
van Kesteren, Gooren,
and Megens (1996)
The Netherlands 1975–1992 1:30,400 1:11,900 1:3 Presented at the clinic with gender dysphoria Total population
Ross, Wa
˚linder, Lundstro
and Thuwe (1981)
Australia 1976–1978 0.58 total 1:150,000 1:24,000 1:6.1 Referrals to a clinic and
diagnosed according to Wa
˚linder (1968)
15 years and older
Eklund, Gooren, and Bezemer
The Netherlands 1976–1986 x 1:54,000 1:18,000 1:3 Started hormone therapy and diagnosed
according to Wa
˚linder (1968)
15 years and older
Blanchard, Clemmensen,
and Steiner (1987)
Canada 1980–1984 x x x 1:1.7 Referred to own clinic due to gender
16 years and older
Weitze and Osburg (1996) West Germany 1981–1990 0.24 total 1:94,000 1:36,000 1:2.3 Applications for legal sex
reassignment to court
Total population
De Cuypere et al. (2007) Belgium 1985–2003 x 1:33,800 1:12,900 1:2.43 Individuals who had underwent SRS 15 years and older
Tsoi (1988) Singapore 1986 x 1:8,300 1:2900 1:3 Applied for SRS and diagnosed, with
transsexualism (DSM-III)
15 years and older
Bakker, van Kesteren,
Gooren, and Bezemer (1993)
The Netherlands 1986–1990 x 1:30,400 1:11,900 1:2.5 Started hormone therapy and diagnosed
according to Wa
˚linder (1968)
15 years and older
De Cuypere, Janes, and Rubens
Belgium 1986–1994 x x x 1:1.7 Diagnosis of transsexualism 15 years and older
Arch Sex Behav
Table 1 continued
Author Country Year or time
Population Prevalence and incidence
calculations based on
Meyer zu Hoberge (2009) Germany 1991–2000
0.34 total
0.26 FM
0.41 MF
1:32,050 1:18,250 1:1.5 Applications for legal sex
reassignment to court
Total population
Olsson and Mo
¨ller (2003) Sweden 1992–2002 0.24 total x x 1:1.9 Applications to court for legal
and surgical sex reassignment
15 years and older
Pimenoff 2006) Finland 1993–2002 x x x 1:1 Application for castration due to
Not stated
Veale (2008) New Zealand 1995–2008 x 1:22,700 1:3600 1:6 Gender change in passport 15 years and older
´mez-Gil et al. (2006) Catalonia 1996–2004
0.73 total 1:48,100 1:21,000 1:2.6 Diagnosed transsexualism (ICD-10) 15–65
Wilson, Sharp, and Carr (1999) Scotland ca. 1998 x 1:31,200 1:7400 1:4 Patients with gender dysphoria with or
without treatment known by GP:
15 years and older
Wilson, Sharp, and Carr (1999) Scotland ca. 1998 x 1:52,100 1:12,800 1:3.8 Receiving hormone therapy or
15 years or older
´mez-Gil, Trilla, Salamero,
´s, and Valde
Barcelona, Spain 2000–2006 x x x 1:2.24 Diagnosed with transsexualism
Not stated
Smith, van Goosen, Kuiper, and
Cohen-Kettenis (2005)
The Netherlands Before 2003 x x x 1:1.5 Completed sex reassignment 15 years of old
Baba et al. (2011) Japanese region
2003–2010 x 1:12,200 1:25,200 2:1 Applying for treatment at a clinic and
diagnosed with GID (DSM-IV)
Total population
Kreukels et al. (2010) Amsterdam,
2009 x x x 1:2.34 Applicants with gender dysphoria data
from own clinic
17 years and older
Kreukels et al. (2010) Ghent, Belgium 2009 x x x 1:2.5 Applicants with gender dysphoria
data from own clinic
16 years and older
Kreukels et al. (2010) Hamburg,
2009 x x x 1.33:1 Applicants with gender dysphoria
data from own clinic clinic
16 years and older
Kreukels et al. (2010) Oslo, Norway 2009 x x x 1.12:1 Applicants with gender dysphoria
from own clinic clinic
16 years and older
Dulko and Imielinski (2004) Poland Not stated x x x 3.4:1 Diagnosis of transsexualism Not stated
Arch Sex Behav
records are classified as secret and kept on file. If the application
is approved, a new national registration number signifying the
new gender is assigned after SRS. The time lapse between
application and permission for surgery and finally a new legal
gender is currently no more than 1 year. Persons who have
undergone SRS abroad can present the Board with a certificate
that they have had surgical sex reassignment and receive legal
gender reassignment without evaluation and real life experi-
ence. The National Board of Health and Welfare also handles
applications for reversal to the original sex in cases of regrets
(regret applications). Regret applications are also accompanied
by a medical certificate. To date, all regret applications have
been approved, which gives the person the right to treatment to
reverse the body as much as possible. All costs for medical care
and pharmacological treatment, except facial surgery, are cov-
ered by the national health insurance.
Subjects and Procedure
All application files from 1960 to 2010 were reviewed with
permission from the Ethical review board, Stockholm, and the
National Board of Health and Welfare. Files from January 1,
2011 to June 30, 2011 were also analyzed in order to determine if
applications were approved or not. We extracted data on
assigned sex at birth, date of birth, date of first visit to a
healthcare provider with a documentation of gender dysphoria,
date of application for legal and surgical sex reassignment or
name change and sterilization if it was a two-step procedure.
Furthermore, date and outcome of the decision (if refused, the
reasons for this), date of new legal gender, whether the person
had undergone sex reassignment abroad, and regre t applications
were extracted. Age of the applicants was calculated based on
the date of the first application. Data were missing for 26 cases
and, for these cases, age at first application was estimated to have
occurred two months before the date of decision if that was
available, or otherwise 12 months before the date of the second
application, or if that was also missing, 24 months before the
date of the new legal gender.
Incidence for the first application per individual was cal-
culated and stratified for four periods between 1972 and 2010
(the time the law has been in force). The means of the total
Swedish population over 17 years of age for the first and the
last year of the 10-year intervals were used for incidence
calculations (Sweden Statistics, 2012). We had no data on the
number of sex reassigned individuals alive and residing in
Sweden at each given time point, which precluded exact point
prevalence figures (total number of cases in the population
divided by the number of individuals in the population) or
lifetime prevalence. However, several previous studies have
reported transsexualism prevalence rates without taking into
account the number of living cases (Baba et al., 2011;De
Cuypere et al., 2007; Tsoi, 1988; Veale, 2008). For compar-
ison reasons, we therefore decided to calculate prevalence
numbers based on all persons who ever applied for a new legal
gender as if they were all alive during the study period. This will
slightly overestimate the point prevalence. The regret rate is
defined as the number of sex reassigned individuals at the time
period when they did their first application that will later apply
for reversal to the original sex, compared to the total number of
individuals who did their first application at that time period and
received a new legal gender. The data were stratified in 10 years’
time periods. The study was conducted in the same way as earlier
Swedish incidence studies (Lande
´netal.,1996; Olsson &
¨ller, 2003;Wa
˚linder, 1971), with the exception that we
calculated incidence rates for the population over 17 instead of
over 14 years of age, since a new legal gender cannot be granted
before 18.
All tables and statistical analyses were generated in the
software package R: A Language and Environment for Sta-
tistical Computing (R Core Team, 2013). For dichotomous
data, cross tabulation with v
or Fisher’s exact test were used
where appropriate. Results were defined statistically signifi-
cant if the pvalue was\0.0001.
Number of Applications, Granted Applications, and Time
to New Legal Gender
A total of 767 people (289 natal females and 478 natal males)
applied for legal and surgical sex reassignment in Sweden due
to transsexualism/gender dysphoria during the period
1960–2010. Figure 2shows the number of natal females and
natal males applying for a new legal gender stratified per year.
Of these 767 applicants, 89 % or 681 persons (FM: 252/289,
87 %; MF: 429/478, 90 %) were granted a new legal gender
and had undergone sex confirmation surgery by the end of
June 2011. Eight individuals (4 FM and 4 MF) of 681 were
assigned a new legal gender before the law came in force
1972. A total of 25 persons (3.3 %, 7 natal females and 18
natal males) were denied a new legal gender due to reasons
listed in Table 2. The mean time between the first visit at any
clinic for gender dysphoria and a new legal gender for the 681
individuals who underwent sex reassignment declined from a
mean of 87 (SD =70) months between 1972 and 1980, to 46
(SD =31) months between 2001 and 2010.
Table 3shows stratified incidence of applications for a new
legal gender for the four periods for each gender. The overall
incidence of applications for a new legal sex increased from
Arch Sex Behav
0.20/100,000/year (1972–1980) to 0.57/100,000/year (2001–
2010). For FMs, there was a 2.5 fold increase from 0.16 to
0.42/100,000/year from the first decade to the last; and for
MFs, there was a threefold increase from 0.23 to 0.73/
100,000/year. The incidence differed significantly between
the time periods for both genders combined, v2ð3Þ¼308,
p\.0001, as well as for FM, v
(3) =107, p\.0001, and MF,
(3), p\.0001. Likewise, the incidence rates for people who
actually received a new sex tripled for both sexes from 0.16 to
0.51/100,000/year (FM: 0.13–0.37/100,000/year, MF:
At the end of December 2010, there were 3,791,791 females and
3,704,685 males over 17 years of age alive and living in Sweden.
This gives a point prevalence for persons who had applied for a
new legal gender of 1:13,120 for FM and 1:7,750 for MF. As of
the same date, the point prevalence for persons who had
undergone legal and surgical sex reassignment in Sweden dur-
ing 2010 was 1:15,047 for FM and 1:8,636 for MF.
Sex Ratio
whole study period, but fluctuated between 1:1.42 and 1:1.93 as
presented in Table 3. The fluctuation of the sex ratio was not
significant over time, v
(3) =2.76. The sex ratio for those who
received a new legal gender was 1:1.53 (1972–1980), 1:1.45
(1981–1990), 1:1.89 (1991–2000), 1:1.73 (2001–2010), and
was 1:1.70 for the whole study period 1960–2010.
Age of Applicants
The median (min–max) age at application for the whole
period was 27 years (16–65) for FMs and 32 years (18–75) for
MFs. The proportion of FMs who were 30 years of age or
older at the time of application remained stable at around
30 %. By contrast, MFs 30 years of age or older increased
from 37 % in the first decade to around 60 % over the last three
decades (see Table 3).
A total of 15 individuals (5 FM and 10 MF) out of 681 who
received a new legal gender between 1960 and 2010 applied
for reversal to the original sex (regret applications). This
corresponds to a regret rate of 2.2 % for both sexes (2.0 % FM
and 2.3 % MF). As showed in Table 4, the regret rate decreased
significantly over the whole study period, Fisher’s exact test,
p\.0001.The median (min–max) age atwhich this group first
applied fora new legal sex was 22 (18–52) years in FM and 35
(27–49) years in MF. The median (range) time elapsed from
attaining a new legal gender to the regret application was
A gender
of gender
of the
F64.0 and
start of sex
to the
Board of
Health and
of the
Board of
Health and
surgery and
new legal
Fig. 1 Procedural flow for
individuals applying for sex
confirmation genital surgery and
new legal sex
Fig. 2 New applicants for a new legal sex and permission for sex
confirmation surgery to the National Board of Health and Welfare in
Sweden, 1960–2010, per year, males and females as assigned at birth
Arch Sex Behav
7.5 years (90 months, range 75–137) for FM, and 8.5 years
(102 months, range 22–177) for MF.
SRS Abroad
A total of 41 persons had surgical sex reassignment abroad: 2
females aged 29 and 42, and 39 males with median (min–max)
age 36 (18–59). Most sex reassignments abroad occurred after
1991 (36/41). The surgery was conducted mainly in Thailand
and the US (36/41) while the remainder took place in the UK,
the Baltic States, or Norway. One of these 41 individuals had
been denied sex reassignment in Sweden prior to surgery
abroad. The rest had not applied for legal and surgical sex
reassignment in Sweden before they underwent their surgery
abroad. Up to 2010, there had been no regret applications from
this group.
We studied the applications for sex reassignment in the total
population of Sweden during 50 years. There was a pronounced
increase of applications from the year 2000. Approximately 2.5
times more FMs and three times more MFs applied between
2001 and 2010 compared to the three previous decades. This
accords with reports from Toronto and the Netherlands where
the number of adolescents who seek help for gender dysphoria
has increased (de Vries & Cohen-Kettenis, 2012;Woodetal.,
2013). The same has also been reportedfrom Catalonia (Go
There are several possible explanations for the increase in
gender reassignment applications. First, a drift in diagnostic
criteria has occurred in that the Legal Board in Sweden has
been increasingly more likely to sanction late onset MF (Ols-
son & Mo
¨ller, 2003). As a consequence, the proportion of MF
Table 2 Applications and outcomes for new legal and surgical sex reassignment submitted to the National Board of Health and Welfare in a Swedish
sample, male or female as assigned at birth, between January 1960 and June 2011
Applications for new legal sex January 1960–
December 2010 (% of all applications)
Assigned female
N=289 (37.7 %)
Assigned male
N=478 (62.3 %)
Total N=767
(100 %)
Granted new legal sex between January 1960 and 30 June 2011,
out of the applications made January 1960–December 2010 (% of all applications)
252 (87.2 %) 429 (89.7 %) 681 (88.8 %)
Permission not granted for new legal sex (% of all applications) 37 (12.8 %) 49 (10.3 %) 86 (11.2 %)
Reasons for not granting new legal sex
Application withdrawn by applicant (% of all applications) 3 (1.0 %) 6 (1.3 %)
9 (1.2 %)
Pending new legal sex; chosen by applicant (% of all applications) 17 (5.9 %) 11 (2.3%) 28 (3.7 %)
Waiting-list for operation (% of all applications) 8 (2.8 %) 9 (1.9 %) 17 (2.2 %)
Partly granted; name-change (% of all applications) 2 (0.7 %) 5 (1.0 %) 7 (0.9 %)
Dismissal of the application (% of all applications) 7 (2.4 %) 18 (3.8 %) 25 (3.3 %)
Reasons for dismissal
Did not meet diagnosis criteria (% of all applications) 2 (0.7 %) 6 (1.3 %) 8 (1.0 %)
Application incomplete (% of all applications) 3 (1.0 %) 9 (1.9 %) 12 (1.6 %)
Co-morbidity (% of all applications) 2 (0.7 %) 0 2 (0.3 %)
Not sterile (% of all applications) 0 1 (0.2 %) 1 (0.1 %)
Missing data (% of all applications) 0 2 (0.4 %) 2 (0.3 %)
One male applicant died during the time period after application and before permission granted and legally accounted as withdrawn
Table 3 Incidence of FM and MF applications/100,000/year stratified in 10-year periods, 1972–2010, with median age and percentage over 30 years
of age at time for application and sex ratio
Year of
FM number/
[17 years/
FM age
FM % above
30 years
old (%)
MF number/
[17 years
MF age
MF % above
30 years
old (%)
1972–1980 45/3,166,037 0.16 29 (16–51) 36 64/3,062,456 0.23 27 (18–55) 37 1:1.42
1981–1990 39/3,340,105 0.12 26 (18–45) 33 52/3,198,147 0.16 33 (18–56) 62 1:1.33
1991–2000 46/3,497,821 0.13 26 (18–65) 28 89/3,347,178 0.27 36 (19–55) 61 1:1.93
2001–2010 153/3,674,613 0.42 27 (17–53) 31 260/3,559,056 0.73 33 (18–75) 59 1:1.70
Arch Sex Behav
in general and late onset MF in particular increased during the
study period. But this occurred back in the 1980s and 1990s and
cannot explain the surge after the turn of the century. Second, it
has been suggested that homophobia in countries like Australia
and Singapore may cause gay males to undergo SRS (Ross et al.,
1981;Tsoi,1988). A recent report from Toronto suggests that
the increased number of applications from adolescents may be
because it is perceived easier to be transsexual than homose xual,
but it is unknown whether this applies to adults (Wood et al.,
2013). A Swedish survey found more tolerant attitudes toward
transsexual than homosexual persons (Lande
2002). Homophobia is nevertheless an unlikely explanation to
an increase in MF:s in Sweden, which rates low on homophobia;
same-sex marriage has for example been allowed for 10 years
(ILGA-Europe, 2013). A third potential explanation could be
easier access to care and better care for transsexualism. Reports
from Singapore and the Netherlands suggest that good care of
gender dysphoric people and especially good surgical tech-
niques for MFs facilitates sex reassignment (Bakker, van
Kesteren, Gooren, & Bezemer, 1993;Tsoi,1988). Since 1999,
evaluation of those who request gender change has been cen-
tralized in Stockholm County (which comprises 20 % of the
Swedish population). Prior to that, care of transsexual individ-
uals was more random and the level of expertise and experience
varied considerably between care providers. Fourth, increased
public awareness, easier access to information, and increasing
societal acceptance of individuals with gender dysphoria may
have contributed to the increased incidence. Internet access in
Swedish households increased from 47 % in 2003 to 91 % in
2010 (Sweden Statistics, 2013) and people with gender dys-
phoria may have become aware of their condition and learned to
seek help via the internet, which also gives the possibility for
easy connections with support groups.
We estimated the point prevalence for individuals who
have been granted a new legal gender and who have under-
gone a complete sex reassignment to be 1:15,047 in FM and
1:8,636 in MF. These figures should be compared with the
prevalence among Belgian-born people who had undergone
complete SRS 2003, as estimated by data retrieved from all
surgical departments in the country, which were 1:33,800 in
FM and 1:12,900 in MF (De Cuypere et al., 2007). The
Swedish figures slightly overestimate the prevalence as we
were not able to exclude those who deceased after sex reas-
signment and those who were born outside Sweden (see
‘‘ Method). But this is unlikely to explain the more than
double prevalence for FM compared to Belgium.
The FM:MF sex ratio in Sweden was rather stable between
1972 and 2010. There was a trend towards more male applicants
during 1991 and 2000 (1:1.93) that abated during the following
decade to 1:1.73. Presumably, several structural and other fac-
tors influence the sex ratio and also the frequency of applica-
tions. Such factors, which may differ across countries, include
access to healthcare and insurance coverage, trust in healthcare
providers, diagnostic traditions, legal possibilities for being
granted a new legal gender, and societal prejudice (Nieder et al.,
2011; Okabe et al., 2008).
The average age at application was stable over the time
period for both genders. FMs were younger (median 27 years
old) than MFs (median 32 years old). These figures are in line
with those from the European Network of the Investigation on
Gender Incongruence (ENIGI) consortium (the clinics in
Amsterdam, Gent, Hamburg, and Oslo) (Nieder et al., 2011). By
contrast, in Singapore and Spain, the mean age was 24–25 years
in both groups (Go
´mez-Gil et al., 2009;Tsoi,1988). This is in
line with the suggestion that applicants for gender reassign-
ment tend to be older in individualistic countries (Sweden is
an individualistic country according to Hofstede’s index that
divides cultures and countries into either individualistic or col-
lectivistic) compared to collectivistic countries like Spain and
Singapore (Lawrence, 2010). The proportion of FMs over 30
years old was stable at 30 %. By contrast, the percentage of
MFs over 30 years of age increased from 37 to 60 % during
the study period. This is most likely related to the change in
the interpretation of the law and diagnostic criteria that
occurred ca. 1985, when also late onset gender dysphoria was
accepted for legal and surgical sex reassignment.
The time from the first appointment for gender dysphoria
until being granted a new legal gender decreased from 7.3 years
Table 4 Individuals who will subsequently apply for reversal to the original sex
Time period Number of sex reassigned individuals at the time
period when they did their first application that will
later apply for reversal to the original sex/total number
of individuals who did their first applications at this
time period who received a new legal sex (%)
Number of regret applications,
during that time period
1960–1971 4/15 (27 %) 0
1972–1980 6/103 (5.8 %) 5
1981–1990 1/76 (1.3 %) 3
1991–2000 3/127 (2.4 %) 3
2001–2010 1/360 (0.3 %) 4
1960–2010 15/681 (2.2 %) 15
Arch Sex Behav
in the first decade (1972–1981) to 3.8 years in the last
(2001–2011). This represents an improvement in care, even
though 3.8 years may still seem unnecessarily long to complete
the entire process. Only 3.3 % of applicants were denied a new
legal gender by the Legal Board of the National Board of Health
and Welfare. This implies good diagnostic precision and selec-
tion of individuals who can proceed to a complete legal sex
change. An alternative interpretation would be that the gender
teams adjusted well to the demands of the legal prerequisites
and, because of this, act as gatekeepers. The 3.3 % (2.4 % FM
and 3.8 % MF) denial rate was slightly higher than has been
reported from Germany: 1 % for FM and 3 % for MF (Meyer zu
Hoberge, 2009).
In June 2011, 30 applicants who had been granted permission
to undergo surgery and subsequently obtain a new legal gender
status (17 females and 13 males) had postponed surgery more
than 12 months (Table 1). It is assumed that these people were
waiting for a change in the Swedish law in order to escape the
requirement to be sterile to be eligible for sex change operation.
By rule of court and EC regulation, this requirement has since
been revoked and the Swedish law changed.
The regret rate defined as application for reversal of the legal
gender status among those who were sex reassigned was 2.2 %
for the whole period 1960–2010 with no significant sex differ-
ence. The risk of regretting the procedure was higher if one had
been granted a new legal gender before 1990 (11/15). For the
two last decades, the regret rate was 2.4 % (1991–2000) and
0.3 % (2001–2010), respectively. The decline in the regret rate
for the whole period 1960–2010 was significant. However, the
last period is still undecided since the median time lag until
applying for a reversal was 8 years. If excluding 2001–2010 the
pvalue is .002. The Swedish regret rate is slightly higher com-
pared to previous reports: 1 % for FM and 1–1.5 % for MF
¨fflin, 1992), 0.4 % for both genders (Weitze & Osburg,
1996), and 0.6 % for both genders (Meyer zu Hoberge, 2009).
This might be explained by the extensive follow-up time in the
present study and by the fact that virtually all cases of regrets are
captured in the Swedish registry system. The FMs who applied
for reversal were younger at application than those who did not
(median 22 years compared to 27 years for the whole FM
group). Conversely, the MFs who later applied for reversal were
older when they applied for sex reassignment than those who did
not (median 35 years vs. 32 years for the whole MF group).
Since the group is small, these data must, however, be inter-
preted cautiously. A previous Swedish study identified lack of
family support and transsexualism secondary to transvestism
(today late onset gender dysphoria) as risk factors for regret
´n, Wa
˚linder, Hambert, & Lundstro
¨m, 1998). Since then,
all gender teams in Sweden include support to next-of-kin,
which hence might have contributed to the decreased rate of
regret. A Canadian study with 84.1 % follow-up rate of at least
one year post SRS identified heterosexual MF as significant
factor for regret (Blanchard, Steiner, Clemmensen, & Dickey,
and can neither confirm nor refute this finding. A German study
identified poor differential diagnosis, failure to carry out the
social transition, and poor surgical result and lack of proper care
in treating the patients as risk-factors for regrets (Pfa
¨fflin, 1992).
Another study identified dissatisfaction with the physical and
functional result of the SRS as a factor for regret to the treatment
(Lawrence, 2003). One could speculate that workup procedures
and surgical treatment have improved since 1990 contributingto
a declined regret rate. It was beyond the scope of this study to
survey details about the regret process and we can neither con-
firm nor refute previous predictors of regret.
About 6 %, more MF than FM, underwent surgical pro-
cedures abroad at their own expense, mostly in the U.S. and
Thailand. This began ca. 1991 and has gradually become
more common. In some instances, it reflects a wish to speed
up the process or avoid the evaluation process.
Although all applications for legal gender reassignment were
included, it is important to emphasize that this study does not
represent all people with transsexualism or gender dysphoria;
there may still be those who do not need or want a medical
transition or have been denied early in the process by health care
providers. The incidence of gender dysphoria/incongruence in a
population, disregarding requests for treatment, is not known in
Sweden but there is some information from the U.S., The
Netherlands, Finland, and Taiwan. In a household probability
sample of adults in Massachusetts, 0.5 % labeled themselves as
transgender (Conron, Scott, Stowell, & Landers, 2012). In a
recent Dutch study, 0.6 % of males and 0.2 % of females were
gender dysphoric (Kuyper & Wijsen, 2014). In a population-
based Finnish sample (222 men and 349 women 18–44 years),
6 % reported that they had felt like the opposite sex and/or
wished they had the body of the opposite gender (A
Santtila, & Sandnabba, 2010). In a college student sample (2,588
men and 2,463 women) from Taiwan, 7.3 % females and 1.9 %
males reported that they often or very often wished to be the
opposite sex (Lai, Chiu, Gadow, Gau, & Hwu, 2010). These data
must be interpreted cautiously due to differences in methodol-
ogy and different definitions of gender dysphoria and impor-
tantly, these figures do not reflect the proportion of people who
need or request medical help to ease their gender dysphoria.
Nevertheless, these studies suggest that some degree of gender
dysphoria is more common than the number of persons who
actually decide to proceed with a gender reassignment. If soci-
etal changes result in increased awareness and acceptance of
gender change, a further increase in incidence cannot be
Strengths and Limitations
This study was unique as it represents a complete n ational cohort
of individuals who have applied for legal gender change in
Sweden over the past 40 years. The quality of the data was
Arch Sex Behav
assuredbyaccesstoalltheoriginal files and applications since
1960 and by the legal framework regulating legal sex change in
Sweden. This contrasts with many studies from other countries
that only pertain to one or a few clinics in a country and therefore
cannot provide reliable prevalence estimates (Baba et al., 2011;
´mez-Giletal.,2006). Moreover, this study covered 50 years
which allows for observation of secular trends over the years.
The methodology was similar to previous Swedish studies, which
allows for comparisons (Lande
˚linder, 1971). A limitation was that the point prevalence
was slightly overestimated (see‘Method). We had no data about
sexual orientation and could therefore not test this factor in rela-
tion to changes in sex ratio or regrets.
Acknowledgments The authors declare that the research was con-
ducted in the absence of any commercial or financial relationships that
could be construed as a potential conflict of interest. Financial support
was provided through the regional agreement on medical training and
clinical research (ALF) between Stockholm County Council and the
Karolinska Institutet, through grants from the Royal Swedish Academy
of Sciences (Torsten Amundson’s Foundation) and from the Clinical
Department of Psychiatry Stockholm Health Care Services. We thank
Linda Almqvist, at the time for data collection legal adviser at The
National Board of Health and Welfare, Stockholm, Sweden for valuable
assistance with data collection and administrative support. We also
thank Dr. Gail Knudson, who generously commented on the article.
˚lgars, M., Santtila, P., & Sandnabba, N. K. (2010). Conflicted gender
identity, body dissatisfaction, and disordered eating in adult men and
women. Sex Roles, 63, 118–125. doi:10.1007/s11199-010-9758-6.
American Psychiatric Association. (1980). Diagnostic and statistical
manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical
manual of mental disorders (3rd ed., rev.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: Author.
Baba, T., Endo, T., Ikeda, K., Shimizu, A., Honnma, H., Ikeda, H., et al.
(2011). Distinctive features of female-to-male transsexualism and
prevalence of gender identity disorder in Japan. Journal of Sexual
Medicine, 8, 1686–1693. doi:10.1111/j.1743-6109.2011.02252.x.
Bakker, A., van Kesteren, P. J., Gooren, L. J., & Bezemer, P. D. (1993).
The prevalence of transsexualism in the Netherlands. Acta
Psychiatrica Scandinavica, 87, 237–238.
Blanchard, R., Clemmensen, L. H., & Steiner, B. W. (1987). Hetero-
sexual and homosexual gender dysphoria. Archive of Sexual
Behavior, 16, 139–152.
Blanchard, R., Steiner, B. W., Clemmensen, L., & Dickey, R. (1989).
Prediction of regrets in postoperative transsexuals. Canadian
Journal of Psychiatry, 34, 43–45.
Conron, K. J., Scott, G., Stowell, G. S., & Landers, S. J. (2012).
Transgender health in Massachusetts: Results from a household
probability sample of adults. American Journal of Public Health,
102, 118–122. doi:10.2105/AJPH.2011.300315.
De Cuypere, G., Janes, C., & Rubens, R. (1995). Psychosocial functioning
of transsexuals in Belgium. Acta Psychiatria Scandinavia, 91, 180–
De Cuypere, G., Van Hemelrijck, M., Michel, A., Carael, B., Heylens,
G., Rubens, R., et al. (2007). Prevalence and demography of trans-
sexualism in Belgium. European Psychiatry, 22, 137–141. doi:10.
de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical management
of gender dysphoria in children and adolescents: The Dutchapproach.
Journal of Homosexuality, 59, 301–320. doi:10.1080/00918369.
Dixen, J. M., Maddever, M., Van Maasdam, J., & Edwards, P. W. (1984).
Psychosocial characteristics of applicants evaluated for surgical
gender reassignment. Archive of Sexual Behavior, 13, 269–276.
Dulko, S., & Imielinski, C. (2004). The epidemiology of transsexualism
in Poland. Journal of Psychosomatic Research, 56, 637.
Eklund, P. L., Gooren, L. J., & Bezemer, P. D. (1988). Prevalence of
transsexualism in the Netherlands. British Journal of Psychiatry,
152, 638–640.
Garrels, L., Kockott, G., Michael, N., Preuss, W., Renter, K., Schmidt,
G., et al. (2000). Sex ratio of transsexuals in Germany: The devel-
opment over three decades. Acta Psychiatria Scandinavia, 102, 445–
Godlewski, J. (1988). Transsexualism and anatomic sex ratio reversal in
Poland. Archives of Sexual Behavior, 17, 547–548.
´mez-Gil, E., Trilla Garcı
´a, A., Goda
´s Sieso, T., Halperin Rabinovich,
I., Puig Domingo, M., Vidal Hagemeijer, A., et al. (2006). Esti-
´n de la prevalencia, incidencia y razo
´n de sexos del transex-
ualismo en Catalun
˜a segu
´n la demanda asistencial [Estimation of
prevalence, incidence and sex ratio of transsexualism in Catalonia
according to health care demand]. Actas Espan˜ olas de Psiquiatrı´a,
34, 295–302.
´mez-Gil, E., Trilla, A., Salamero, M., Goda
´s, T., & Valde
´s, M. (2009).
Sociodemographic, clinical, and psychiatric characteristics of trans-
sexuals from Spain. Archives of Sexual Behavior, 38, 378–392. doi:10.
Hoenig, J., & Kenna, J. C. (1974). The prevalence of transsexualism in
England and Wales. British Journal of Psychiatry, 124, 181–190.
ILGA-Europe, the European Region of the International Lesbian, Gay,
Bisexual, Trans and Intersex Association. (2013). The rainbow
map and index. Retrieved from
Kreukels, B. P., Haraldsen, I. R., De Cuypere, G., Richter-Appelt, H.,
Gijs, L., & Cohen-Kettenis, P. T. (2010). A European network for
the investigation of gender incongruence: The ENIGI initiative.
European Psychiatry, 27, 445–450. doi:10.1016/j.eurpsy.2010.04.
Kuyper, L., & Wijsen, C. (2014). Gender identities and gender dysphoria
in the Netherlands. Archives of Sexual Behavior, 43, 377–385.
Lai, M. C., Chiu, Y. N., Gadow, K. D., Gau, S. S., & Hwu, H. G. (2010).
Correlates of gender dysphoria in Taiwanese university students.
Archives of Sexual Behavior, 39, 1415–1428. doi:10.1007/s10508-
´n, M., & Innala, S. (2000). Attitudes toward transsexualism in a
Swedish national survey. Archives of Sexual Behavior, 29, 375–
´n, M., & Innala, S. (2002). The effect of a biological explanation
on attitudes towards homosexual persons. A Swedish national
sample study. Nordic Journal of Psychiatry, 56, 181–186. doi:10.
´n, M., Wa
˚linder, J., Hambert, G., & Lundstro
¨m, B. (1998). Factors
predictive of regret in sex reassignment. Acta Psychiatrica Scan-
dinavica, 97, 284–289.
Arch Sex Behav
´n, M., Wa
˚linder, J.,& Lundstro
¨m, B. (1996).Prevalence, incidence
and sex ratioof transsexualism.Acta PsychiatricaScandinavica, 93,
Lawrence, A. A. (2003). Factors associated with satisfaction or regret
following male-to-female sex reassignment surgery. Archives of
Sexual Behavior, 32, 299–315.
Lawrence, A. A. (2010). Societal individualism predicts prevalence of
nonhomosexual orientation in male-to-female transsexualism.
Archives of Sexual Behavior, 39, 573–583. doi:10.1007/s10508-
Meyer zu Hoberge, S. (2009). Prevalence, incidence and sex ratio of
transsexualism in Germany established by counting applications of
the German Transsexual Act during the period 1991 until 2000.
Unpublished doctoral thesis, Medical Faculty Christian-Albrechts-
¨t zu Kiel, Kiel, Germany.
Nieder, T. O., Herff, M., Cerwenka, S., Preuss, W. F., Cohen-Kettenis, P.
T., De Cuypere, G., et al. (2011). Age of onset and sexual orien-
tation in transsexual males and females. Journal of Sexual Medi-
cine, 8, 783–791.
O’Gorman, E. C. (1982). A retrospective study of epidemiological and
clinical aspects of 28 transsexual patients. Archives of Sexual
Behavior, 11, 231–236.
Okabe, N., Sato, T., Matsumoto, Y., Ido, Y., Terada, S., & Kuroda, S.
(2008). Clinical characteristics of patients with gender identity
disorder at a Japanese gender identity disorder clinic. Psychiatry
Research, 157, 315–318. doi:10.1016/j.psychres.2007.07.022.
Olsson, S. E., & Mo
¨ller, A. R. (2003). On the incidence and sex ratio of
transsexualism in Sweden, 1972–2002. Archives of Sexual Behav-
ior, 32, 381–386.
Pauly, I. (1968). The current status of change of sex operation. Journal of
Nervous and Mental Disease, 147, 460–471.
¨fflin, F. (1992). Regrets after sex reassignment surgery. Journal of
Psychology and Human Sexuality, 5, 69–85.
Pimenoff, V. (2006). On the care of transsexuals in Finland. Interna-
tional Journal of Transgenderism, 9, 23–33.
R Foundation for Statistical Computing. (2013). R: A Language and
Environment for Statistical Computing, Vienna, Austria. Retrieved
Ross, M. W., Wa
˚linder, J., Lundstro
¨m, B., & Thuwe, I. (1981). Cross-
cultural approaches to transsexualism. A comparison between
Sweden and Australia. Acta Psychiatrica Scandinavica, 63, 75–82.
Smith, Y. L., van Goozen, S. H., Kuiper, A. J., & Cohen-Kettenis, P. T.
(2005). Transsexual subtypes: Clinical and theoretical signifi-
cance. Psychiatry Research, 137, 151–160.
Sørensen, T., & Hertoft, P. (1980). Sexmodifying operations on transsex-
uals in Denmark in the period 1950–1977. Acta Psychiatrica Scan-
dinavica, 61, 56–66.
Sørensen, T., & Hertoft, P. (1982). Male and female transsexualism: The
Danish experience with 37 patients. Archives of Sexual Behavior,
11, 133–155.
Sweden Statistics. (2012). Befolkningsstatistik. Retrieved from http://
Sweden Statistics. (2013). Tillga˚ ng till it-utrustning och internet i hemmet
fo¨ r personer i a˚ ldern 16-74 a˚r. A
˚r 2003–2012. Retrieved from http://
Tsoi, W. F. (1988). The prevalence of transsexualism in Singapore. Acta
Psychiatrica Scandinavica, 78, 501–504.
van Kesteren, P. J., Gooren, L. J., & Megens, J. A. (1996). An
epidemiological and demographic study of transsexuals in the
Netherlands. Archives of Sexual Behavior, 25, 589–600.
Veale, J. F. (2008). Prevalence of transsexualism among New Zealand
passport holders. Australian and New Zealand Journal of Psychi-
atry, 42, 887–889.
Vujovic, S., Popovic, S., Sbutega-Milosevic, G., Djordjevic, M., &
Gooren, L. (2008). Transsexualism in Serbia: A twenty-year
follow-up study. Journal of Sexual Medicine, 6, 1018–1023.
˚linder, J. (1968). Transsexualism: definition, prevalence, and sex
distribution. ActaPsychiatrica Scandinavica, 203(Suppl.), 2 55–258.
˚linder, J. (1971). Incidence and sex ratio of transsexualism in
Sweden. British Journal of Psychiatry, 119, 195–196.
Weitze, C., & Osburg, S. (1996). Transsexualism in Germany: Empirical
data on epidemiology and application of the German Transsexuals’
Act during its first ten years. Archives of Sexual Behavior, 25, 409–425.
Wilson, P., Sharp, C., & Carr, S. (1999). The prevalence of gender
dysphoria in Scotland: A primary care study. British Journal of
General Practice, 49, 991–992.
Wood, H., Sasaki, S., Bradley, S. J., Singh, D., Fantus, S., Owen-
Anderson,A., Zucker, K. J. (2013).Patterns of referral to a gender
identity service for children and adolescents (1976–2011): Age, sex
ratio, andsexual orientation[Letter to the Editor].Journal of Sex and
Marital Therapy, 39,16.doi:10.1080/0092623X.2012.675022.
World Health Organization. (1992). The international statistical clas-
sification of diseases, and related health problems (10th ed.).
Geneva: Author.
Zucker, K. J., & Lawrence, A. A. (2009). Epidemiology of Gender
Identity Disorder: Recommendations for the Standards of Care of
the World Professional Association for Transgender Health.
International Journal of Transgenderism, 11, 8–18.
Arch Sex Behav
... Características de los estudios incluidos 24,35,36,49,53,55,57,58,66,82,87,89,91,[94][95][96]98,114 presenta una recopilación de los términos empleados en la literatura junto a su definición y las relaciones de significado existentes entre ellos. ...
... En primer lugar, el criterio de destransición, en las pocas ocasiones en las que aparece explícitamente definido, difiere significativamente entre estudios. En algunos de ellos se basa en la manifestación explícita de arrepentimiento y la demanda de tratamientos de reversión 34,36 , mientras que en otros se basa en la solicitud de reversión legal y médica 35,86,93 , la reversión al género original 55,58,82,86 o el cambio/cese de la identidad transgénero 48,53,66,89,92 (ver Tabla 3). La falta de uniformidad entre los datos, así como la caracterización de la destransición tan específica o incluso restrictiva que se plantea en algunos artículos 105 , es una fuente potencial de sesgo y distorsión de las estimaciones, además de impedir llevar a cabo comparaciones entre ellas. ...
... El uso de intervalos de seguimiento limitados reduce drásticamente la posibilidad de inclusión de aquellas personas cuyos procesos de destransición comienzan varios años después de las primeras intervenciones médicas realizadas. De hecho, diversos estudios retrospectivos, entre los que destacan el sueco 35 , los españoles 49,66 y el holandés 36 , han informado de casos de destransición transcurridos entre cuatro y 23 años desde el inicio del proceso de transición médica. Es necesario, por tanto, mantener la precaución a la hora de interpretar las cifras de destransición procedentes de estudios con intervalos de seguimiento reducidos. ...
Full-text available
Introducción. La destransición de género es el acto de detener o revertir los cambios sociales, médicos y/o administrativos con- seguidos durante un proceso de transición de género. Se trata de un fenómeno emergente de gran interés a nivel clínico y social. Método. Se condujo una búsqueda sistemática en siete bases de datos entre 2010 y 2022, se rastrearon manualmente las referencias de los artículos y se consultaron libros especializados. Se realizó un análisis cuantitativo y de contenido. Resultados. Se incluyeron 138 registros, 37% correspondientes a estudios empíricos y 38,4% publicados en 2021. Se identifican al menos ocho términos para hacer referencia a la destransición, con diferencias en sus definiciones. La prevalencia difiere en función del criterio utilizado, siendo menor para la destransición/arrepentimiento (0-13,1%) que para la descontinuación de la asistencia/tratamiento médico (1,9%-29,8%), y menor para la destransición/arrepentimiento tras cirugía (0-2,4%) que para la destransición/arrepentimiento tras tratamiento hormonal (0-9,8%). Se describen más de 50 factores psicológicos, médicos y socioculturales que influyen en la decisión de destransicionar, así como 16 factores predictores/asociados a la destransición. No se encuentran guías de abordaje sanitario ni legislativo. Los debates actuales se centran en los interrogantes sobre la naturaleza de la disforia de género y el desarrollo de la identidad, el papel de los profesionales con respecto al acceso a los tratamientos médicos y el impacto de las destransiciones sobre la futura accesibilidad a dichos tratamientos. Conclusiones. La destransición de género es una realidad compleja, heterogénea, poco estudiada y escasamente comprendida. Se requiere un abordaje y estudio sistemático que permita comprender su prevalencia real, implicaciones y manejo a nivel sanitario.
... Although it is difficult to determine the exact prevalence of people who detransition, overall, the estimates for detransition or regret following hormonal and/or surgical treatments (0-9.8%) 24,[34][35][36][37]48,49,[53][54][55]57,58,66,82,[86][87][88][89][90][91][92][93][94][95]98 are notably lower than those for discontinuation of care/medical treatment (1.9-29.8%) 36,53,55,62,92,[95][96][97][98][99] . ...
... Similarly, the figures for detransition or regret following gender-affirming surgery (0-2.4%) 24,[34][35][36][37]49,53,55,57,66,86,88,90,93,100 are lower than those after hormonal treatment (0-9.8%) 24,48,49,[53][54][55]66,87,89,92,94,95,98,100 . ...
... In some, it is based on the explicit expression of regret and the request for reversal treatment 34,36 . In contrast, in others, it is based on the request for legal and medical reversal 35,86,93 , the reversion to the original gender 55,58,82,86 , or the change/ cessation of a transgender identity 48,53,66,89,92 (see Table 3). The lack of consistency in the data, as well as the very specific or even restrictive characterization of detransition in some articles 105 , is a potential source of bias and distortion in the estimates and prevents comparisons between them. ...
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Introduction. Gender detransition is the act of stopping or reversing the social, medical, and/or administrative changes achieved during a gender transition process. It is an emerging phenomenon of significant clinical and social interest. Methods. We systematically searched seven databases between 2010 and 2022, manually traced article references, and consulted specialized books. Quantitative and content analyses were carried out. Results. We included 138 registers, 37% of which were empirical studies and 38.4% of which were published in 2021. At least eight terms related to detransition were identified, with differences in their definitions. Prevalence estimates differ according to the criteria used, being lower for detransition/regret (0-13.1%) than for discontinuation of care/medical treatment (1.9%-29.8%), and for detransition/ regret after surgery (0-2.4%) than for detransition/ regret after hormonal treatment (0-9.8%). More than 50 psychological, medical, and sociocultural factors influencing the decision to detransition and 16 predictors/associated factors are described. No health or legal guidelines are found. Current debates focus on the nature of gender dysphoria and identity development, the role of professionals in accessing medical treatments, and the impact of detransition on future access to these treatments. Conclusions. Gender detransition is a complex, heterogeneous, under-researched, and poorly understood reality. A systematic study and approach to the topic is needed to understand its prevalence, implications, and management from a healthcare perspective.
... Discontinuation can overlap with regret and/ or detransition, or neither (for instance, when due to health concerns alone). The percentage of people who discontinue, detransition, and/or regret is not known, outside of some very narrowly defined study populations (Dhejne et al., 2014). ...
... Observed average or median times to regret or detransition (for different samples, interventions, measures of regret or detransition, as noted) include those for the four studies in Table 1, listed chronologically. The two regret studies listed include either a large percentage of those who had gonadectomies in the Netherlands (Wiepjes et al., 2018) or all those still living who had genital surgeries in Sweden (Dhejne et al., 2014), finding small numbers of patients (14 and 15, of 2627 and 681, respectively) who qualified as regretters with their criteria. The other two studies are convenience samples of detransitioners only, 237 in Vandenbussche (2022) and 100 in Littman (2021), with a range of interventions (31% in Vandenbussche, 2022, only socially transitioned). ...
... The median or average time to detransition or regret range from 3.2 years in Littman (2021) for female-to-male, for a range of medical interventions, to an average of 130 months for gonadectomy (Wiepjes et al., 2018). The average and median regret times in Dhejne et al. (2014) and Wiepjes et al. (2018), where all had genital surgeries of some kind, were longer than the average detransition times in Littman (2021) and Vandenbussche (2022), where different interventions were considered. The studies in Table 1 all point to long times to reach even half of the regrets or the average time to detransition, but are at best rough estimates, as the surgical regret samples are small (Dhejne et al., 2014;Wiepjes et al., 2018), and the interventions for the much larger samples of detransitioners are heterogeneous (Littman, 2021;Vandenbussche, 2022). ...
... Regret is broadly defined as a negative, cognitive-based emotion involving counterfactual inference and feelings of personal agency or self-blame (Zeelenberg & Pieters, 2007). Studies evaluating regret following medical transition have used non-standardized definitions, and methods to ascertain regret have been heterogeneous Dhejne et al., 2014;Lawrence, 2003;Narayan et al., 2021;Pfäfflin, 1993;Rehman et al., 1999;van de Grift et al., 2018;Weyers et al., 2009;Wiepjes et al., 2018). Likewise, definitions of detransition vary across studies, but most include discontinuing medications, having surgery to reverse the effects of transition, or both (Exposito-Campos, 2021;Littman, 2021;Vandenbussche, 2022). ...
... Historical data suggest that regret following gender transition in adulthood is rare Dhejne et al., 2014;Lawrence, 2003;Pfäfflin, 1993;Rehman et al., 1999;van de Grift et al., 2018;Weyers et al., 2009;Wiepjes et al., 2018). However, studies reporting low rates of regret are generally from an era when hormonal therapy and surgery were only undertaken under strict protocol. ...
... Regret was ascertained by a variety of methods, including retrospective review of medical charts for documentation of regret, or unvalidated questionnaires and semi-structured interviews, which are susceptible to non-response bias Lawrence, 2003;Rehman et al., 1999;van de Grift et al., 2018;Weyers et al., 2009;Wiepjes et al., 2018). Other researchers have used a very narrow definition of regret, such as application to have birth sex reinstated as legal sex (Dhejne et al., 2014). More recently, patients with post-operative regret were identified using requests for surgical reversal, although it is unknown what proportion of those who experience regret pursue further surgery (Narayan et al., 2021). ...
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Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.
... Aliás, Ehrensaft [29] e Nichols [23] afirmam que se deverá ter atenção e cuidado com crianças que querem "reverter" o processo de afirmação, já que estas poderão sentir receio em provocar o desapontamento de figuras parentais e de pessoas do círculo social próximo. O processo de arrependimento é pouco frequente, mas pode ocorrer [30], havendo cerca de 2% de pessoas Trans que "reverteram" [31], sendo a maioria jovens adultos que iniciaram o processo uns anos antes, que não tinham apoio social, sofriam de estigma e discriminação, e que tiveram sequelas devido a intervenções cirúrgicas que correram mal [32]. Contudo, é preciso apontar que a maioria das pessoas que afirma o seu género fica feliz com as suas escolhas [33]. ...
Combining a philosophical approach with empirical psychology, this essay investigates the relationship between “profilicity,” the formation of identity in orientation to profiles, and gender identity. We discuss empirical research that indicates a significant difference between transgender identity in traditional (collectivist) and modern (individualist) societies. We suggest that this difference is due to a shift in the formation of gender identity away from gender roles and toward gender profiles. To substantiate this claim, we first outline a basic theoretical terminology of identity and gender. Then, we critically analyze the representation of gender, including transgender, in contemporary popular culture. Finally—with a descriptive, but not therapeutic intention—we discuss several case studies of identity formation of transgender people. We conclude that theoretical problems arising from historical shifts in gender identity formation, including transgender identity formation, are best conceptualized in terms of profilicity rather than in the still prevailing semantics of authenticity.
This gold standard text has kept its readers abreast of rapid advancements in reproductive medicine and surgery since 1983. Continuing this tradition, this fifth edition has been fully updated and revised to provide clear, didactic advice on best practice for a variety of clinical situations faced by practitioners across many specialties - including urologists, gynecologists, reproductive endocrinologists, medical endocrinologists and many in internal medicine and family practice who see men with suboptimal fertility and reproductive problems. Completely restructured to include pedagogical features such as easily accessible key concepts that cement understanding and real-world use. Covering everything from foundations of anatomy and embryology, through clinical evaluation, diagnostic approaches, treatment and fertility care in context within the healthcare system and society, thrilling advances and future directions are also included. This new edition is an essential reference for all who are working in this young and rapidly evolving field.
Although transition regret and detransition are often dismissed as rare, the increasing number of young detransitioners who have come forward in recent years to publicly share their experiences suggests that there are cracks in the gender-affirmation model of care that can no longer be ignored. In this commentary, I argue that the medical community must find ways to have more open discussions and commit to research and clinical collaboration so that regret and detransition really are vanishingly rare outcomes. Moving forward, we must recognize detransitioners as survivors of iatrogenic harm and provide them with the personalized medicine and supports they require.
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Kinnon MacKinnon and colleagues call for robust, sensitive research to inform comprehensive gender care services for people who detransition
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Using data draw from the follow-up literature covering the last 30 years, and the author's clinical data on 295 men and women after SRS, an estimation of the number of patients who regretted the operations is made. Among female-to-male transsexuals after SRS, i.e., in men, no regrets were reported in the author's sample, and in the literature they amount to less than 1%. Among male-to- female transsexuals after SRS, i.e., in women, regrets are reported in 1-1.5%. Poor differential diagnosis, failure to carry out the real-life- test, and poor surgical results seem to be the main reasons behind the regrets reported in the literature. According to three cases observed by the author in addition to personality traits the lack of proper care in treating the patients played a major role.
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Formal epidemiological studies on the incidence and prevalence of gender identity disorder (GID) or transsexualism have not been conducted. Accordingly, crude estimates of prevalence have had to rely on indirect methods, such as parental endorsement of behavioral items pertaining to GID on omnibus questionnaires for children and youth or the number of adult patients seeking contra-sex hormonal treatment or sex-transformative surgery at hospital- or university-based gender clinics. Data from child and adolescent parent-report questionnaires show that the frequent wish to be of the other sex is quite low but that periodic cross-gender behavior is more common. In the general population, cross-gender behavior is more common in girls than it is in boys but boys are referred to gender identity clinics more frequently than are girls. Prevalence estimates of GID in adults indicate that it is higher in natal males than in natal females although this may be accounted for by between-sex variation in sexual orientation subtypes. Prevalence estimates of GID in adults based on clinic-referred samples suggest an increase in more recent cohorts. It remains unclear whether this represents a true increase in prevalence or simply greater comfort in the seeking out of clinical care as professionals become more attuned to the psychosocial and biomedical needs of transgendered people.
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The relation between gender identity and body dissatisfaction as well as disordered eating was examined in a population-based sample of Finnish adults aged 18 to 44years (N = 1,142). Participants with a conflicted gender identity were compared to controls matched on age and biological sex. Participants with a conflicted gender identity showed higher levels of body dissatisfaction, women with a conflicted gender identity also showed more eating disturbance than controls. Among men with a conflicted gender identity, male–male sexual experience was associated with more body dissatisfaction and disordered eating. Among women with a conflicted gender identity, female–female sexual experience was related to less body dissatisfaction. Possible explanations for these findings and the potential clinical implications are discussed. KeywordsBody dissatisfaction-Body image-Disordered eating-Gender identity
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The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth's functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.
Several studies estimate the prevalence of gender dysphoria among adults by examining the number of individuals turning to health services. Since individuals might be hesitant to seek medical care related to gender dysphoria, these studies could underestimate the prevalence. The studies also lack information regarding the variance among different aspects of gender dysphoric conditions. Therefore, the current study estimated the prevalence by examining self-reported gender identity and dysphoria in a Dutch population sample (N = 8,064, aged 15-70 years old). Three measures assessed aspects of gender dysphoria: gender identity, dislike of the natal female/male body, and wish to obtain hormones/sex reassignment surgery. Results showed that 4.6 % of the natal men and 3.2 % of the natal women reported an ambivalent gender identity (equal identification with other sex as with sex assigned at birth) and 1.1 % of the natal men and 0.8 % of the natal women reported an incongruent gender identity (stronger identification with other sex as with sex assigned at birth). Lower percentages reported a dislike of their natal body and/or a wish for hormones/surgery. Combining these figures estimated the percentage of men reporting an ambivalent or incongruent gender identity combined with a dislike of their male body and a wish to obtain hormones/surgery at 0.6 %. For women, this was 0.2 %. These novel findings show that studies based on the number of individuals seeking medical care might underestimate the prevalence of gender dysphoria. Furthermore, the findings argue against a dichotomous approach to gender dysphoria.
The aim of this report is to give a brief description of the development of the Finnish treatment programme for persons with transsexual symptoms and to point out some traits which are particularly characteristic of the Finnish legal provisions and clinical framework and might have an impact on the choices of the individual patient.
The prevalence of transsexualism in Singapore was estimated by counting all the patients who sought sex-reassignment surgery and were subsequently diagnosed as transsexuals by psychiatrists. Up to 1986, there were a total of 458 Singapore-born transsexuals, of which 343 were males and 115 were females. This was a prevalence of 35.2 per 100,000 population age 15 and above (or 1/2900) for male transsexualism, and 12.0 per 100,000 (or 1/8300) for female transsexualism. The sex ratio was about 3 males to 1 female. The main reason for the high prevalence was the availability of sex-reassignment surgery.