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

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DOI: 10.1007/s10508-014-0300-8 · Source: PubMed
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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.
An Analysis of All Applications for Sex Reassignment Surgery
in Sweden, 1960–2010: Prevalence, Incidence, and Regrets
Cecilia Dhejne
Katarina O
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-
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 1 summarizes 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/year
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.,
). 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 theLegal 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 1 illustrates 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 and
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 Presentedat the clinic with genderdysphoria 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 regret 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 sameway 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 p value 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 2 shows 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 3 shows 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, v
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
3,704,685males 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
and2.3 % MF).As showedin Table 4, the regret rate decreased
significantly over the whole study period, Fisher’s exact test,
p\.0001. The median (min–max) age at which this group first
applied for a 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 beenreportedfrom 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 homosexual,
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
p value 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 contributing to
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 national 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 (seeMethod). 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
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  • ... Transgender medicine gender teams with specialists in psychiatry, psychology, endocrinology, plastic surgery, speech and language pathology, dermatology, gynecology, and andrology have been available at the Swedish university hospitals including ours since 1999 for diagnostic evaluation, support, and gender-affirming treatment including hormone treatment, top surgery, gender-affirming genital surgery, voice treatment and hair removal. 24,25 In connection with the 2012 change in the legislation, 12 the Reproductive Medicine unit of Karolinska University Hospital became a part of the extended transgender medicine team of the hospital. ...
    Full-text available
    Background As gender-affirming treatment may have a negative impact on fertility, reproductive health counseling to patients seeking medical or surgical gender-affirming treatment should be provided, including the option to undergo fertility preservation (FP). Experiences of transgender men undergoing FP treatments aimed at oocyte freezing have reported a negative impact of the treatments on gender dysphoria. No previous studies have investigated the experiences of health care professionals’ (HCP) when caring for transgender men undergoing such treatments. Aim The aim of this study was to investigate HCP’s attitudes and experiences when meeting transgender men undergoing FP through oocyte freezing. Methods Individual interviews were conducted in 2016 with 13 HCPs working at a Reproductive Medicine clinic in Sweden. Data were analyzed by thematic content analysis. Results The main theme found, How to maintain professionalism, showed that HCPs experienced important challenges to their professionalism when their preconceived opinions and values about gender and transgender were confronted. Discussion Our findings demonstrate the need of continuous efforts on assessing learning needs as well as addressing preconceived opinions and values of HCP. By gaining knowledge and self-confidence in the care of transgender individuals undergoing FP, a professional care for transgender people can be achieved and a safe environment can be established for the patients. This in turn may alleviate some of the distress that may arise when transgender men undergo FP.
  • ... 3 Many transgender individuals report recognition of gender identity differing from sex assigned at birth during prepubescence, although the mean age of presentation is 27 to 32 years. 4,5 There is a growing number of patients presenting for gender-affirming treatment and a trend toward decreasing age at time of presentation. 6 In the United States, 0.7% of individuals aged 13 to 24 years identify as transgender. ...
    Transgender individuals represent a small, albeit growing, patient population that is encountered more frequently in clinical care due to improved insurance coverage and increasing awareness. Gender-affirming treatments, including both gender-affirming hormone therapy and gender-affirming surgery, pose significant risks to fertility potential and outcomes, ranging from potentially impaired fertility rates to full elimination of reproductive potential depending on the type of treatment pursued. However, there are relatively limited data specific to fertility preservation for transgender individuals. Current approaches to treatment are extrapolated from options for fertility preservation after oncologic diagnoses. In this review, we aim to summarize current clinical approaches, fertility preservation options, and patient experiences in fertility preservation for transgender individuals. Several forms of fertility preservation options are available depending on the pubertal status of a transgender individual. Despite the multiple options for fertility preservation, major barriers exist to patient care and there are reports of mixed patient experiences. Further awareness of this clinical situation and understanding of these processes will allow for comprehensive and specialized care for transgender individuals who may otherwise miss opportunities for adequate counseling or treatment options regarding fertility preservation.
  • ... There are no studies to support these claims. However, recent studies show only a very small percentage of people who undergo gender transition as adults (when irreversible procedures may be administered) regret doing so: less than 2.2%, which is a small number compared with rates of regret reported for much more common procedures (Dhejne et al., 2014;Wiepjes et al., 2018). Most people who have regrets do so because of a lack of support or acceptance from their family, social groups, work, or other organizations. ...
  • ... En España la prevalencia sigue siendo mayor para la población MtF . (2003) " ----1, 9/1 Landen et al., (1996) " ----1,4/1 Wålinder (1971) " ----1/1 Dhejne et al., (2014) " 1/13.120 1/7.750 0,6/1 Pauly (1968) USA 1/100.000 ...
    Full-text available
    La transexualidad se caracteriza por una marcada incongruencia entre género y sexo biológico. La población transexual busca la transición “hombre-mujer” (MtF) o “mujerhombre”(FtM). La literatura muestra una mayor concordancia entre gemelos monocigóticos que dicigóticos, lo que sugiere la contribución genética. Objetivos: Esta investigación consistió en el análisis citogenético y molecular del cariotipo de una población transexual. Posteriormente se realizó el análisis molecular de siete polimorfismos genéticos, cuatro de repetición: ERα-rs3138774, ERβ-rs113770630, AR rs193922933 y CYP19-rs60271534, y tres polimorfismos de única base (SNPs): ERα-rs2234693, ERα-rs9340799 y CYP17-rs743572, en una población de 974 transexuales y 1.327 controles. El diagnóstico y selección de la muestra se realizó en las Unidades de Identidad de Género de los Hospitales Clínic (Barcelona) y Carlos Haya (Málaga). Material y Métodos: El análisis del cariotipo se realizó mediante bandas G y el microarray Affymetrix CytoScan™ high-density. El estudio de los polimorfismos consistió en la amplificación de las regiones polimórficas y posterior establecimiento de los genotipos mediante electroforesis capilar (3130 XL Genetic Analyzer), o mediante digestión enzimática en el caso de los polimorfismos de única base. El análisis de las frecuencias se realizó con los tests Mann-Whitney o Chi-cuadrado y el software SPSS® 23.0. El análisis de interacción se realizó mediante regresión logística binaria con el software SNPStats. Los falsos positivos se excluyeron con la corrección de Bonferroni. Resultados: Los receptores de estrógenos alfa y beta están implicados en la base genética de la transexualidad. La población FtM mostró mayor número de repeticiones CA (ERβ-rs113770630) que la población control. Las frecuencias alélicas y genotípicas del ERα- rs9340799 (genotipo A/A) fueron también significativas en la población FtM. Se encontraron combinaciones alélicas significativas entre ERα-rs9340799, ERβ-rs113770630 y AR-rs193922933 en la población MtF. Conclusión: Los receptores de estrógenos alfa y beta juegan un papel clave en la diferenciación sexual del cerebro en nuestra especie.
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    Full-text available
    The number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological well‐being (Paediatrics, 2014, 134, 696). However, some people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231). Certainly, despite their presence in all follow‐up studies of young people who have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.
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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.