Viability of sex reassignment surgery

+ Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. The authors of the study surveyed 247 trans women (100 of those who had surgey). They administered a questionnaire made from three surveys. The first part asked about the person’s age and their transition, the second part asked six questions related to their face, and the third part was the San Francisco 36-question health questionnaire (SF36v2).
		- Limitations:
			* While the size of the sample is sufficient: 247 people (100 who had surgery, 147 who did not), the sample may not be representative. Participants were recruited from people who had received care from an FFS (Facial Feminization Surgery) surgeon or clinic and people who were involved in transgender support groups or organizations. Most of the surveys were given online, but a paper version was given at a transgender health conference.
			* People who have seen a surgeon are more likely to be well-off; FFS costs mentioned on one forum ranged from $23,000  to $64,000. The low end of the spectrum was for surgery abroad. If the trans women answering the survey were in fact richer than the general public, it would explain why they had better physical health than most women. It might also mean that they should have had a better mental health quality of life than most women. If the trans women answering the survey were in fact richer than the general public, it would explain why they had better physical health than most women. It might also mean that they should have had a better mental health quality of life than most women.
			* Another limitation is that trans women who had had surgery were significantly different from the trans women who had not had surgery. The differences were important and relevant to the study’s results.
				+ 95% of the trans women who underwent surgery were also taking hormones while only 66% of the non-surgery group were taking hormones.\* It may be that the hormones and not the surgeries were responsible for the improved well-being. ***"Hormone therapy may have had an effect to the reported quality of life of our sample" -p.3***
				+ 54% of the trans women who underwent surgery had transitioned more than five years ago while only 24% of the non-surgery group had transitioned more than five years ago.\* It may be that being further along in transition was responsible for the improved well-being. There are many reasons this could be true including more time for family adjustment, having had more therapy, or knowing more about how to present as a woman. This could also be that some people find that transition does not help them in the first few years of transition and drop out; this might mean that the group of people who are further along in transition does not include as many people who have difficulties with transition.
			* A possible conflict of interest is that Dr. Spiegel of the study is an expert in facial feminization surgery which may mean he has a bias in favor of believing that it works.

* Bailey, Ellis, & McNeil, 2014
	+ Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt
		- Limitations may include the fact that this research is not demographically representative despite its large sample size; ***"the study relied on respondents self-selecting and therefore will not necessarily be demographically representative of the trans population as a whole."*** (n=889).
		- This study is a narrative analysis meaning it is scientifically dispositive
* Glynn et al., 2016
	+ The role of gender affirmation in psychological well-being among transgender women. n=573
		- Limitations
			* Participants were recruited through purposive sampling by identifying community spaces and venues where transgender women congregate which may bias the results as they are not random
			* Since these transgender women were chosen specifically with a history of sex work, this may not be representative of the population.
			* Rather than analyzing well being over time, Glynn uses a one-time self-report survey that assessed demographic characteristics, gender affirmation, and mental health outcomes
			* Given the cross-sectional nature of the study, we cannot infer temporal order or causal pathways among variables; it may be that individuals who have higher psychological well-being report being more affirmed, perhaps because they are more likely to be active in causing their environment to be more affirming.
			* Due to the geographic context and inclusion criteria guiding study recruitment, this sample may not be representative of other transgender communities; findings might not generalize to communities in less liberal or inclusive environments, or the broader transgender community who do not have any history of sex work due to socioeconomic and racial/ethnic differences.
			* This study only examined familial support as one specific facet of social affirmation; the measurement of medical affirmation may limit findings as it should be noted that having any gender affirmative surgeries or using hormones is an individual decision; these interventions might not be needed or desired by all transgender individuals.
* Dhejne et al., 2014
	+ An analysis of all applications for sex reassignment surgery in Sweden, 1960-2010: prevalence, incidence, and regrets
		- Limitations
			* The first problem is that this methodology probably under-counts the regret rate, as its definition of regret overlooks those who were unhappy with their transition but did not apply to reverse it. It would not count those who succumbed to depression or addiction, or who lived unhappily after transition.
			* This analysis fails to include a related study by some of the same researchers showed a horrifyingly high rate of suicide among its post-surgery subjects—nineteen times that of the general population. Finally, this data is drawn from a population with strict pre-transition screening, and the results likely do not apply where transition is less regulated. It is dangerous to assume that the regret rate of rigorously screened Swedish adults will apply to poorly screened American adolescents.
* Rotondi et al., 2011
	+ Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians
		- Limitations
			* Despite being the largest transgender study in Canada at the time of publication (n=207), a limitation that is addressed in this study is “respondent-driven sampling”- using a large, network-based sample of trans people. The self-selecting nature of the study means it isn't representative of the general Ontario transgender community. (for example, the general transgender community skews older than those sampled)
			* This study was based on one-time self-reported data (rather than a diagnosis of clinical depression) without a control to compare to.
* Boza and Nicholson, 2014
	+ Gender-Related Victimization, Perceived Social Support, and Predictors of Depression Among Transgender Australians
		- The majority of respondents were sourced via gender-related support services. (convenience sampling) n=255
		- This study is a cross-sectional analysis.
		- This study does not differentiate between depression arising from temporal fluctuations compared to depression arising from victimization

### Studies with a sample size lower than 200

for modern social science research, one must need a sufficient sample size to find a reliable effect from the data

* Bar et al., 2016
	+ Male-to-female transitions: Implications for occupational performance, health, and life satisfaction
		- Limitations
			* The sample size is incredibly low (n=44) which may reduce the chance of detecting the true effect of sex reassignment surgery.
			* The transgender women in this study were not in the same stage of transition which mans the transgender women who are still in the process of transition, their occupational performance and life satisfaction may not have finished the upward trajectory shown in the analysis. Potentially, their scores would be higher at a later stage of the transition
			* Since this study is cross sectional, we can not deduce that improvement of sex reassignment surgery is causally correlated to health and life satisfaction.
* Bodlund and Kullgren, 1996
	+ Transsexualism--general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex (Longitudinal study)
		- Limitations
			* Despite the fact that these 19 transgender patients represent the total population of all known transsexuals in the process of sex reassignment within their respective region, there are not enough people being studied in this study to make conclusive findings
* Bouman et al., 2016
	+ Sociodemographic Variables, Clinical Features, and the Role of Preassessment Cross-Sex Hormones in Older Trans People.
		- Limitations
			* This study has an incredibly small sample size (n = 74)
			* This study is a cross-sectional analysis. Future research could investigate underlying motives as to countries.
* Budge et al., 2013
	+ Transgender Emotional and Coping Processes
		- Limitations
			* This study has an incredibly small sample size (n = 18)
			* All but three of the participants in this study were recruited from LGBT community centers.
* Cardoso da Silva et al., 2016
	+ Before and After Sex Reassignment Surgery in Brazilian Male-to-Female Transsexual Individuals
	+ (longitudinal)
		- Limitations
			* This study has an incredibly small sample size (n = 47)
* Castellano et al., 2015
	+ Quality of life and hormones after sex reassignment surgery
		- Limitations
			* This study has an incredibly small sample size (n = 60)
* Colizzi, Costa, & Todarello, 2014
	+ Transsexual patients' psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: results from a longitudinal study
* Colizzi et al., 2013
	+ Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style
* Colton-Meier et al., 2011
	+ The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals
* Costantino et al., 2013
	+ A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery
* Davis and Meier, 2014
	+ Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People
* De Cuypere et al., 2006
	+ Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery
* Eldh, Berg, & Gustafsson, 1997
	+ Long-term follow up after sex reassignment surgery
* Fisher et al., 2014
	+ Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria
* Gomez-Gil et al., 2012
	+ Hormone-treated transsexuals report less social distress, anxiety and depression
* Gomez-Gil et al., 2014
	+ Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery
* Gorin-Lazard et al., 2012
	+ Is hormonal therapy associated with better quality of life in transsexuals? A cross-sectional study
* Gorin-Lazard et al., 2013
	+ Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals
* Hess et al., 2014
	+ Satisfaction with male-to-female gender reassignment surgery
* Heylens et al., 2014
	+ Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder
* Imbimbo et al., 2009
	+ A report from a single institute's 14-year experience in treatment of male-to-female transsexuals
* Johansson et al., 2010
	+ A five-year follow-up study of Swedish adults with gender identity disorder
* Keo-Meier et al., 2015
	+ Hormone-treated transsexuals report less social distress, anxiety and depression
* Kraemer et al., 2008
	+ Body image and transsexualism
* Landen et al., 1998
	+ Factors predictive of regret in sex reassignment
* Lawrence, 2003
	+ Factors associated with satisfaction or regret following male-to-female sex reassignment surgery
* Lawrence, 2006
	+ Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery
* Lindqvist et al., 2017
	+ Quality of life improves early after gender reassignment surgery in transgender women.
* Lobato et al., 2006
	+ Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort
* Manieri et al., 2014
	+ Medical Treatment of Subjects with Gender Identity Disorder: The Experience in an Italian Public Health Center
* Megeri and Khoosal, 2007
	+ Anxiety and depression in males experiencing gender dysphoria
* Nelson, Whallett, & Mcgregor, 2009
	+ Transgender patient satisfaction following reduction mammaplasty
* Newfield et al., 2006
	+ Female-to-male transgender quality of life
* Padula, Heru, & Campbell, 2016
	+ Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis
		- ***This isn't even a relevant study. Padula attempts to mathematically model the cost/benefit of gender transition, rather than providing original research on the effects of transition***
* Parola et al., 2010
	+ Study of quality of life for transsexuals after hormonal and surgical reassignment
* Pfäfflin, 1993
	+ Regrets After Sex Reassignment Surgery
* Pimenoff and Pfäfflin, 2011
	+ Transsexualism: Treatment Outcome of Compliant and Noncompliant Patients
* Rakic et al., 1996
	+ The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes
* Rehman et al., 1999
	+ The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients
* Ruppin and Pfäfflin, 2015
	+ Long-Term Follow-Up of Adults with Gender Identity Disorder
* Smith et al., 2005
	+ Follow-up study of transsexuals after sex-reassignment surgery
* Van de Grift et al., 2017a
	+ Effects of Medical Interventions on Gender Dysphoria and Body Image: a Follow-up Study
* van de Grift et al., 2017b
	+ Surgical Satisfaction, Quality of Life and Their Association After Gender Affirming Surgery: A Follow-up Study
* Vujovic et al., 2009
	+ Transsexualism in Serbia: A Twenty-Year Follow-Up Study
* Weigert et al., 2013
	+ Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals
* Weyers et al., 2009
	+ Long-term assessment of the physical, mental, and sexual health among transsexual women

### 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being.

* Barrett, 1998
	+ Psychological and social function before and after phalloplasty
* Lindqvist et al., 2017
	+ Quality of life improves early after gender reassignment surgery in transgender women.
* Simonsen et al., 2016
	+ Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality
* Udeze, 2008
	+ Psychological functions in male-to-female transsexual people before and after surgery