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ORIGINAL PAPER
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
´n
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
Introduction
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
e-mail: cecilia.dhejne@karolinska.se
K. O
¨berg S. Arver
Department of Medicine/Huddinge, Karolinska Institutet,
Stockholm, Sweden
M. Lande
´n
Institute of Neuroscience and Physiology, Sahlgrenska University
Hospital, Gothenburg, Sweden
M. Lande
´n
Department of Medical Epidemiology and Biostatistics,
Karolinska Institutet, Stockholm, Sweden
123
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
(Go
´mez-Giletal.,2006; Hoenig & Kenna, 1974;Lande
´n,
Wa
˚linder, & Lundstro
¨m, 1996; Meyer zu Hoberge, 2009;Ols-
son & Mo
¨ller, 2003;Ross,Wa
˚linder, Lundstro
¨m, & Thuwe,
1981;Sørensen&Hertoft,1980;Wa
˚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
´netal.,1996;Olsson&Mo
¨ller,
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.
Method
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
123
Table 1 Incidence, prevalence, and sex ratio of transsexualism in different countries
Author Country Year or time
period
Incidence/
100,000/year
Prevalence
FM
Prevalence
MF
Sex
ratio
FM:MF
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
individuals
15 years and older
Hoenig and Kenna (1974) England and
Wales
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
Wa
˚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
Wa
˚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
Lande
´n, Wa
˚linder,
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
¨m,
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
(1988)
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
dysphoria
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
(1995)
Belgium 1986–1994 x x x 1:1.7 Diagnosis of transsexualism 15 years and older
Arch Sex Behav
123
Table 1 continued
Author Country Year or time
period
Incidence/
100,000/year
Prevalence
FM
Prevalence
MF
Sex
ratio
FM:MF
Population Prevalence and incidence
calculations based on
Meyer zu Hoberge (2009) Germany 1991–2000
incidence
1981–2000
prevalence
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
transsexualism
Not stated
Veale (2008) New Zealand 1995–2008 x 1:22,700 1:3600 1:6 Gender change in passport 15 years and older
Go
´mez-Gil et al. (2006) Catalonia 1996–2004
prevalence
2000–2004
incidence
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
post-surgery
15 years or older
Go
´mez-Gil, Trilla, Salamero,
Goda
´s, and Valde
´s(2009)
Barcelona, Spain 2000–2006 x x x 1:2.24 Diagnosed with transsexualism
(ICD-10)
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
Hokkaido
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,
Netherlands
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,
Germany
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
123
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 &
Mo
¨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.
Statistics
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
2
or Fisher’s exact test were used
where appropriate. Results were defined statistically signifi-
cant if the pvalue was\0.0001.
Results
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.
Incidence
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
123
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
2
(3) =107, p\.0001, and MF,
v
2
(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:
0.20–0.66/100,000/year).
Prevalence
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
TheFM:MFsexratioforthosewhoappliedwas1:1.66forthe
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
2
(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).
Regrets
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
raeydrihTraeydnoceSraeytsriF
A gender
dysphoric
individual.
Diagnostic
evaluation
of gender
team,
F64.0?
Confirmation
of the
diagnosis
F64.0 and
start of sex
confirmation
somatic
treatment.
Application
to the
National
Board of
Health and
Welfare.
Decision
and
permission
of the
National
Board of
Health and
Welfare.
Sex
confirmation
surgery and
new legal
sex.
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
123
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.
Discussion
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
´mez-
Giletal.,2006).
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 %)
a
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 %)
a
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
application
FM number/
female
population
[17 years/
FM
incidence/
100,000/
year
FM age
median
(min–max)
FM % above
30 years
old (%)
MF number/
male
population
[17 years
MF
incidence/
100,000/
year
MF age
median
(min–max)
MF % above
30 years
old (%)
Sex
ratio
FM:MF
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
123
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
´n&Innala,2000,
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
123
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
(Pfa
¨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
(Lande
´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,
1989).Wehadnodataonsexualorientationinthepresentstudy
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
˚lgars,
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
excluded.
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
123
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;
Go
´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
´netal.,1996;Olsson&Mo
¨ller,
2003;Wa
˚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.
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