“Social transition” is an intervention in which adults and peers affirm the perceived gender identity of a gender-dysphoric person by using preferred name and pronouns, encouraging gender-stereotypical clothing and hairstyles, and/or endorsing the notion that medical changes will resolve the dysphoria. Viewed by many Democrats as the “kind” or “respectful” way to help the dysphoric person, socially transitioning children and young people is a relatively new phenomenon and emerging research indicates that it is not benign. In fact, social transition is the most powerful predictor of persistence of childhood gender dysphoria. Dr. Hilary Cass, former president of Britain’s Royal College of Pediatrics and Child Health, who was appointed to conduct an independent review of Britain’s largest gender clinic, concluded that social transition should not be seen as a “neutral act” but rather an active intervention that strongly impacts a child or young person’s psychological functioning.

Binding describes a method of flattening the breasts in order to approximate the appearance of a male or non-feminine chest. Duct tape, “trans tape,” “binders,” and tight sports bras are falsely promoted as acceptable and safe ways to reduce the protrusion of breasts in girls. Much like foot-binding, chest-binding comes with potential health risks, including the following: Breathing problems Reduced mobility Compressed or broken ribs Punctured or collapsed lungs Back pain Chest pain Lightheadedness Compression of the spine Skin problems including acne, itch, rash, lesions, infections, reduced skin elasticity Damaged breast tissue Damaged blood vessels Blood clots Inflammation of the ribs Heart attacks Some LGBTQ+ organizations actually offer programs to distribute free binders through the mail.

Tucking involves compressing male genitals into the groin or up between the legs to produce a flat “feminine” appearance – in some cases actually pushing the testicles up into the inguinal canals into the body. Everything is then secured in place with tape, tight underwear, or a “gaff.”(compression underwear). The function of the testicles is to produce sperm and testosterone. To do this, they need to maintain a lower temperature than body temperature, which is why they normally remain outside of the body. Tucking is associated with the following health impacts: Mechanical damage due to pulling or tearing Urinary trauma or infections Scrotal content pain, including the possibility of torsion Infertility Prolonged tucking may cause: Urinary reflux Symptoms of prostatism or infection including epididymorchitis, prostatitis, or cystitis Tucking the penis back between the legs can cause damage from compression, and can also increase the risk of infection, from the penis being close to the anus.

Puberty blockers are pharmaceutically manufactured hormones prescribed to stop the natural hormone-based processes that occur during puberty. The processes include development of secondary sex characteristics (body changes in girls including breasts and hip growth, and the onset of periods, and in males, deeper voices, facial hair, Adam’s apples, and maturation of the genitals). Blockers are given by injection (Lupron and Triptorelin) or are surgically inserted under the skin in the form of small flexible rods (histrelin acetate). Puberty blockers were initially developed and approved for use in advanced prostate cancer. Lupron has also been used to chemically castrate sex offenders by decreasing their sex drive; and to treat precocious puberty in young children. Lawsuits from adverse effects of Lupron are pending. No long-term studies have been conducted to determine the safety or efficacy of these drugs. Administering puberty blockers to children with gender-related distress is an off-label use. States vary in their requirement of parent consent before administering this drug. Due to the lack of long-term data for puberty blocker use during correctly-timed puberty, there is concern about the effect of the drug on neurodevelopment — specifically development of the prefrontal cortex, which is tied to planning, working memory, organization, and modulating mood. Prefrontal cortex maturation is related to improved reasoning skills, impulse control, and understanding long-term consequences. Concerns about the impact on fertility and sexual function are unknown. Blockers may also affect bone growth and height. Essentially all children put on blockers progress to cross-sex hormones. Blockers appear to solidify gender distress, not relieve it. Known side effects, which may or may not be permanent, include: Psychological problems including depression, volatility, and suicidality Bone mineral loss, potentially leading to osteoporosis Increased pressure in the head (pseudotumor cerebri) that can cause swelling of the optic nerve and result in vision loss Males who started blockers early in puberty and who move from blockers directly onto cross-sex hormones — as is the case for essentially all teens prescribed blockers — results in underdeveloped genitals, sterility, and the inability to orgasm. Studies indicate that negative effects on mental health in children prescribed puberty blockers is seen more often than improvement. https://doi.org/10.1080/0092623X.2023.2281986

Individuals who report gender distress to doctors or therapists are typically offered opposite-sex hormones. Widely available through online pharmacies and gender clinics, these synthetic drugs are easily accessible, and are often prescribed with no review of medical records, no psychological evaluation, no physical health exam, and little explanation of the risks and long term adverse health consequences. At age 18, teens can get a prescription for opposite-sex hormones in “informed consent” clinics without parental consent. The informed consent model is closely aligned with the “gender-affirming” model and requires only that a patient has signed a form — no review of medical records, no psychological evaluation, no physical health exam is necessary. Informed consent does not mean that counseling or complete or accurate information was given. In some states and under certain circumstances, teens younger than 18 can acquire hormones legally. Planned Parenthood is the second largest provider of opposite-sex hormones, and follows the informed consent model. It is possible to receive opposite-sex hormones on the first visit to Planned Parenthood or after a virtual phone consultation.

Testosterone is the primary male sex hormone and is largely produced by the testes in males. Testosterone is used by females to masculinize their appearance, an off-label use, and is commonly taken by intramuscular injection into the leg or buttocks, administered every one to two weeks. Testosterone has antidepressant qualities. Use in women causes irreversible effects, including permanent lowering of voice, an increase in facial hair and body hair, and an increase in the size of the clitoris. Observed side effects include: Psychological effects: anxiety, insomnia, aggression Acne Lowered Bone density and osteoporosis in the spine Certain hormone-dependent cancers Vaginal atrophy — thinning of vaginal walls and poor lubrication of vaginal tissues, leads to tearing, micro-abrasions, bleeding, and painful intercourse Symptoms of menopause Erythrocytosis, a condition which slows the blood flow, and can lead to headaches, confusion, high blood pressure, nosebleeds, blurred vision, itching and fatigue Fertility loss Premature death Eventual hysterectomy due to uterine atrophy Women who take testosterone greatly increase their risk of cardiovascular problems, including: Blood clots Cardiovascular disease High blood pressure Heart attack Stroke https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616494/

Estrogen is the primary female sex hormone and is largely produced by the ovaries. Estradiol, the synthetic version, is prescribed to males in order to feminize their appearance. It can be taken in pill, gel, patch, or injectable forms. Estradiol causes irreversible and somewhat reversible body changes, including fat redistribution, growth and development of breast tissue, reduction of muscle mass, reduction of body hair (and to a lesser extent, facial hair), changes in sweat and odor patterns, reduction and possible reversal of male-pattern baldness, and reduced sexual function including reduced erections and sex drive, reduction in or loss of sperm production, and shrinkage of the testicles. Estradiol causes the following neurological effects in males: Reduced water content within the glial or “glue” cells called astrocytes and the oligodendrocytes as well as the axons in the brain, thereby reducing the cortical white matter integrity in the brain, which is related to cognitive instability Increased relative concentration of glutamate and glutamine in the brain, which is associated with Parkinson’s, Alzheimer’s, and Huntington’s disease.” Decreased brain cortical volume, which is associated with general intelligence. Lower cortical volume is also linked to schizophrenia and bipolar disorder.” Other physiological effects include: Increased risk of blood clots and stroke. Increased immune responses toward allergy and worsened asthma attacks, and progress to more severe autoimmune diseases. Increased autoimmune diseases such as rheumatoid arthritis, spondyloarthritis (characterized by low back pain), systemic lupus erythematosus (the most common type of lupus, where the body’s immune system attacks its tissues in joints, skin, brain, lungs, kidneys, and blood vessels), systemic sclerosis, and vasculitis, which results in the destruction of blood vessels. Research has also shown a strong association between gender identity disorder and multiple sclerosis in transwomen. Decreased insulin sensitivity (also known as increasing insulin resistance among diabetes patients) — a sign that the body is having difficulty metabolizing glucose, which can indicate wider health problems such as high blood pressure and cholesterol levels. Estrogen is associated with depression and nearly double the rate of suicidality for young men. https://www.pittparents.com/p/a-man-called-hank-parts-lll-and-iv

Finasteride (brand name: Propecia) is an FDA-approved drug for men for treatment of male-pattern baldness. It works by blocking testosterone from converting to another hormone called dihydrotestosterone which is known to play a role in scalp hair loss. Common side effects of Finasteride in men are erectile disfunction, breast enlargement and (added by the FDA in June 2022), depression and suicidal ideation. Men from around the world have reported adverse, persistent sexual, physical, and mental side effects even after stopping use of Finasteride. This drug induced syndrome of persistent side effects is known as “Post-Finasteride Syndrome” (PFS). In men, Finasteride use is controversial due to the risk of developing PFS symptoms that can have a devastating effect on a person’s sexual function and mental state. Finasteride is being prescribed off-label in gender-affirming medicine. It is being prescribed to men taking estrogen for its anti-androgen properties and to women taking testosterone who are concerned about hair loss. The manufacturer provides a clear warning that it is not indicated for use in women. According to the PFS Foundation, some women who have been prescribed Finasteride have reported similar mental and neurological symptoms to those experienced by male patients.

Metoidioplasty is genital plastic surgery that cuts the ligaments that anchor the clitoris to the pubic bone to release the clitoris so it will resemble a small penis, averaging 2.5 inches long. Prior to metoidioplasty a woman will take testosterone for 6-12 months to enlarge the clitoris. Metoidioplasty may be done all at once or divided into stages. The techniques can vary depending on patient goals and individual anatomy. The procedure takes 2-5 hours with additional surgeries as needed for repair of complications. Complications following metoidioplasty range from urinary dribbling (temporary or permanent) and urine spraying to scarring of the urethra (the tube that carries urine) or fistula (an abnormal connection between two body parts). Other complications include formation of bulges on the colon (diverticula), urinary tract infections, cystitis, incontinence, urinary retention, persistent bladder spasms, and problems with sexual function. The likelihood of revision surgery is high. Overall, complications include compromised function and depression. Metoidioplasty will not create a phallus capable of penetrative sex and may not allow for standing urination, often a stated goal for trans-identifying females. Urination may require that pressure be applied to the surrounding tissues Djordjevic ML et al (2021). Metoidioplasty: Surgical Options and Outcomes in 813 Cases. Front. Endocrinol. Volume 12. doi.org/10.3389/fendo.2021.760284

Phalloplasty is the creation of a phallus or artificial penis from a tissue flap that is cut from the arm, leg, or trunk, rolled into a tube, and attached to the pubic area in order to allow the woman to urinate standing up, have penetrative intercourse, appear “intact” around men, and/or feel more masculine. Phalloplasty is major reconstructive surgery that requires grafts, flaps, microsurgery. Surgeons do not agree on the best method or series of steps so there is no “gold standard.” Most surgery centers divide the phalloplasty into 2-4 surgeries spread out over 12-18 months or more. The graft surgery may take up to 10 hours. Recovery is difficult — for the first 4 weeks post-op, the hips must not bend so only standing and lying down are allowed. Complications are common. Because the neophallus is not made from genital tissue, it will not have the erogenous sensation of a penis. It consists of skin and fat so cannot become erect nor penetrate during sex without an implant. Implants have a high failure rate. In addition, the urethra is simply a tube of skin surrounded by fat with no elasticity so urine may dribble out after voiding. Women may also choose to have a vaginectomy — removal of the vaginal lining and closure of the vaginal opening. Hysterectomy is required two months prior. Fake testicles can be implanted into a pouch created from the labia majora. According to a 2022 meta-analysis, 76.5% of phalloplasty surgeries result in complications. Risks include urethral complications, wound breakdown, pelvic bleeding or pain, bladder or rectal injury, lack of sensation, prolonged need for drainage, and/or need for further procedures. The area from where the skin that is harvested to create the neophallus (typically the forearm) is likely to be permanently scarred and patients may suffer from decreased mobility, blood clots, pain, and decreased sensation. Patients are not always satisfied with the resulting size, shape, or functionality of the neophallus. WARNING. THESE STUDIES CONTAIN DISTURBING IMAGES OF SURGERY Complication rates for these surgeries are high — around 25% for constructing the phallus and up to 64% for urethroplasty, commonly known as urethra lengthening. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3901910/ Berli JU et al (2019). Phalloplasty: techniques and outcomes. Transl Androl Urol., 8(3): 254–265. doi: 10.21037/tau.2019.05.05

Cosmetic mastectomy — breast removal surgery — is a common procedure for trans-identified women. It is almost always referred to by the euphemisms “Top Surgery” or “Masculinizing Chest Surgery”. Medically, the procedure is a modified double mastectomy that removes all or most of the breast tissue with excess skin and fat, but not the underlying pectoral muscles. A woman may have the nipple-areolas removed entirely or choose some combination of nipple reduction to a male size, areola reshaping to the small male oval, transplanting to a more masculine lateral position as a free graft, or leaving the nipple-areolas in the same location. In a handout provided to prospective “gender affirming” mastectomy patients, Kaiser Permanente details possible complications, including: Unsatisfactory permanent scarring Need for revision or further surgery, tattooing (1 out of 3 patients require additional procedures) Breast size fluctuation with future weight gain or loss Partial or complete loss of nipple and areola, nipple flattening Hypersensitivity and or pain of chest skin, nipple and areola, which could be permanent Loss of nipple sensation, erotic sensation (permanent with free nipple grafting) Lightening of the color of the skin around the nipple, especially in patients with darker skin Blood clots in your legs or lungs Chest unevenness/asymmetry, puckering of incisions, excess skin Wound separation/delayed wound healing Complications from anesthesia or medications Difficult psychological adjustment Negative impact on relationships with a significant other or sexual partner No assurance of achieving the desired breast size /shape Poor cosmetic outcome Bleeding (4-10 % chance of emergency return to operating room) Infection The most obvious negative outcome is regret with no way to recover lost body parts. In particular, those women that later wish to breastfeed will not be able to do so. More than an important bonding activity for mother and baby, breastfeeding provides a convenient and free source of nutrition, transferring antibodies to the baby and reducing risks for certain illnesses and conditions while reducing the mother’s risks of breast and ovarian cancer, type 2 diabetes, and high blood pressure. The American Academy of Pediatrics, which supports mastectomy for gender-confused 13-17 year olds “when appropriate,” recommends breastfeeding from birth through age 2.

Hysterectomy is the removal of the uterus (and, in some cases, the ovaries and cervix). While some women may have elective hysterectomies to feel more masculine and eliminate their need for cervical exams, other women have hysterectomies because testosterone shrinks the uterus and causes pelvic pain. The surgical techniques (laparoscopic or vaginal) are the same as in non-trans-identified women but are euphemistically referred to as “masculinizing surgery” or “gender affirming hysterectomies.” If the ovaries are removed with the uterus, pre-menopausal women will not make estrogen and will be dependent on synthetic hormones for proper health and bone density. This means that if they detransition or if they stop testosterone, they have to take estrogen until the natural menopausal age. The most common complications of hysterectomy are: infections (which occur in 9 to 13% of patients); blood clots; urinary, genital and/or gastrointestinal tract injuries; bleeding; and nerve injury. For women who have not reached menopause, menstruation will stop. For those women whose hysterectomies include removal of the ovaries, menopause will quickly begin with symptoms including hot flashes, vaginal dryness, night sweats, and insomnia. Pregnancy is no longer possible after hysterectomy. This realization may lead to depression and regret.

Orchiectomy is the removal of the testicles. Orchiectomy is an outpatient procedure with relatively low complication risk, often performed on men with testicular, breast or prostate cancer. In the case of a trans-identified male, the removal of the testicles is usually performed before or during sex reassignment surgery. https://www.healthline.com/health/mens-health/orchiectomy With the removal of the testicles, the body no longer has the ability to produce normal levels of healthy hormones. This can affect bone density, especially if the person is unable or unwilling to continue their prescription for synthetic hormones at any point in their lifetime. Side effects include: pain or redness around the incision pus or bleeding from the incision fever over 100°F inability to urinate hematoma, which is blood in the scrotum and usually looks like a large purple spot loss of feeling around your scrotum Side effects of having less testosterone in your body, including: osteoporosis loss of fertility hot flashes feelings of depression erectile dysfunction

Vaginoplasty is the process of creating a “neovagina” by inverting the penis to create an opening in the body between the urethra and rectum. A depth of at least five inches is attempted to allow for penetrative sex. If there is not adequate skin from the penis to achieve this, skin grafts are taken from donor sites on other parts of the body. Orchiectomy (removal of testicles) is also done during this procedure. Labia majora are created using scrotal skin. A facsimile of a clitoris is created from a portion of the glans penis. The created “neovagina” does not have the ability to self-clean or produce its own lubrication. To maintain the opening that was created during surgery, and to prevent it from healing over, dilation of the opening is required for the remainder of the patient’s life if they would like to maintain the neovagina. Common complications of vaginoplasty include: General surgical risks — bleeding, infection, and anesthetic accidents, and blood clots in the deep veins Severe scarring, making future corrective surgeries impossible, and also making the individual sensitive about the unsightliness of the perineum and vulva Rectovaginal wall perforations, also called a fistula — an abnormal connection or opening between lower bowel and neovagina, leading to fecal matter entering the neovagina Colitis (inflammation of the large intestine in the neovagina as well as diversion colitis in the closed-off end Peritonitis — inflammation of the lining of the abdomen Neovaginal stenosis — narrowing of the created opening Urinary meatal stenosis — narrowing of the urethral opening Nerve damage in the perineal and pelvic area, leading to hypoesthesia, loss of sensation or numbness, or dysesthesia, abnormal feelings of itching, crawling, stinging, tingling, or prickling, and pain. Nerve damage can also cause chronic pain Painful intercourse Paralytic ileus — temporary paralysis of the muscles of the small intestine or colon Constipation Difficulty urinating Anorgasmia — inability to orgasm Excessive mucus production requiring wearing a sanitary pad Odor or discharge due to bacterial overgrowth or colonization Patients often need secondary or revision procedures https://www.news-medical.net/health/Vaginoplasty-Risks-and-Complications.aspx Vaginoplasty has an overall complication rate of 32.5% (about one in three cases) and a reoperation rate of 21.7% (more than one in five cases). It is sometimes necessary to have a second or third revision surgery to repair stenosis (narrowing of opening) and fistulas. https://pubmed.ncbi.nlm.nih.gov/30269882 https://www.news-medical.net/health/Vaginoplasty-Risks-and-Complications.aspx Data shows that suicide rates of males following vaginoplasty are elevated. https://www.auajournals.org/doi/10.1097/JU.0000000000001971.20

Breast augmentation is the implantation of silicone implants to achieve larger breast size then what might be obtained on estrogen alone. Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection, damage to nearby structures, and an adverse reaction to anesthesia. Other complications include: Suture rupture along an incision line Visible scarring Fluid accumulation beneath the skin A solid swelling of clotted blood within your tissues An imbalance in facial features Dissatisfaction with appearance after surgery A facial nerve injury resulting in chronic pain

A range of surgical procedures aiming to change the shape of the face to look feminine. Examples include hairline lowering to create a smaller forehead, lip and cheekbone augmentation, and reshaping and resizing of the jaw and chin, as well as a face-lifts. Complications include the general surgical issues (bleeding, infection, damage to nearby structures, and an adverse reaction to anesthesia, as well as: Suture rupture along an incision line Visible scarring Fluid accumulation beneath the skin A solid swelling of clotted blood within your tissues An imbalance in facial features Dissatisfaction with appearance after surgery A facial nerve injury resulting in chronic pain www.mayoclinic.org/tests-procedures/facial-feminization-surgery/about/pac-20467962

Tracheal reduction surgery (chondrolaryngoplasty) removes cartilage near a male’s Adam's apple (the neck bulge that appears during puberty). The surgery is desired by trans-identifying males (and some with nonbinary identities) because a prominent Adam’s apple is a clear indicator of one’s sex. A small, horizontal incision is made on the bottom of the Adam's apple, throat muscles are held apart with forceps, the protruding cartilage is shaved down with a scalpel, and the incision is closed with sutures. Newer versions of this surgery hide the incision beneath the chin or inside the mouth. When performed at the same time as other facial feminization surgeries, a general (vs local) anesthetic is needed raising the risk of complications. Because the Adam’s apple is near the vocal cords, there is a risk that this surgery will affect a patient’s voice. If this happens, additional vocal surgery may be needed including “feminization laryngoplasty” to retighten the vocal cords. Infections can occur near the incision site.

Nullification surgery is the removal of external genitalia and other sex-specific structures. This typically includes the removal of the penis and testicles for males or the removal of the breasts, uterus, and ovaries for females, and body contouring. The urethra is preserved (but may be shortened) to allow urination. Some individuals may also choose additional procedures to enhance the nullification effect. Complications for nullification surgery depend on what body parts are being removed/altered. (See previous sections for details on each type of surgery.) There hasn’t yet been much research on negative nullification surgery outcomes. Nullification surgery cannot be reversed. Removing sex organs will make the patient infertile.