gender reassignment the omnivore trials

Victims Say Man Secretly Living In Their Home Planned Gender Reassignment and Arm Removal Surgeries on Them

"He wanted to play doctor on us ... and not in the cute little kid way."

The Campbell family opened up about their horrifying experience after discovering a total stranger had secretly been living in their Hawaii home -- all while planning "to perform various surgeries on us."

In Monday's premiere episode of Lifetime's "Phrogging: Hider In My House," James and Brittany Campbell shared their story, which initially made headlines back in 2019. "Phrogging" is the terrifying phenomenon where people discover others secretly living in their homes -- in places like the walls, crawl spaces and attics.

After getting married and moving to Honolulu with two children in 2019, the Campbells first started noticing little things were off. The two found boxes opened in the garage, belongings shifting around, their webcam appearing on at night and Brittany hearing the door slam "out of nowhere." James, however, admitted he thought "she was being paranoid" and he was "getting frustrated" with his wife. Brittany, on the other hand, said the experience left her "on the verge of a complete mental breakdown."'

James also recalled seeing the shadow of a person outside their home one day, before coming across a curious message left on a desk calendar. It read, "Your rehabilitation starts today. Do as I did: Choose a house, clean it, set up all devices." He, however, assumed Brittany wrote it for him and simply wanted him to clean the house.

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In September 2019, the family returned to the mainland for a week. When they got back to Hawaii, they first noticed James' bike was left in the driveway; immediately, they knew something was wrong. Having the kids wait in the car, James opened the garage and "saw that it had just been completely trashed."

When he went to open the door to get into the house, he was met with resistance. "It opens a crack and we can see a person inside our house," said Brittany -- as James added, "There's a man peeking through the door, he's trying to hold it shut and the man says, 'This is not your house,' very calmly."

James then realized the mystery man was wearing his clothes and started to think maybe the guy was homeless, needed a place to stay and was on drugs. The man reassured the two that he "took care of your cat" while they were gone, as Brittany ran inside to check on their pet. They found it inside a cage, without water. She also said the home looked like the man had been "doing an inventory" of everything inside.

Police came and arrested him, with the Campbells saying he "was very casual" about the whole ordeal. "It was really as if this person didn't think he was doing anything out of the ordinary," said Brittany.

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As the family continued to check out what the man, who was identified in the press as Ezequiel Zayas at the time , they noticed that he had done all of their sons' laundry and made their beds, leaving the room "immaculate." In their own bedroom, things got even freakier.

They found a towel set up with knives on it, next to a pair of their computers. On one computer, there was a text document on the screen titled, "The Omnivore Trials: a rehabilitation for rat like people," as well as "intimate details" about things he "could have only known if he was listening to our private conversations." Explained Brittany: "He somehow knew my husband and I were trying to have a baby. He wrote that I should give up on trying to have a baby and focus on the children that I have. This person had been watching us."

She told The Post that the man "wanted to play doctor on us -- and not in the cute little kid way," saying he wanted to "make us into perfect people." On the episode, the two explained just how he planned to do it.

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"These writings were suggesting that surgical procedures should be performed on my wife and my children. We found these serums that are labeled to use on the 'omnivores,'" he claimed. "He had been looking up videos on how to surgically remove and\ arm, he looked up how to do gender reassignment surgery."

Brittany says the man had also looked at websites to buy surgical tables, as well as how to perform certain surgeries at home. "He had researched ways to implement these plans that he had," she said. Another computer, meanwhile, had a video on it in which Zayas appeared to be "mocking" her -- with footage of him doing "like a makeup tutorial with a really bizarre twist on it."

"There's not even a single part of me that would have thought, 'Hey, there's a guy maybe in our attic writing a medical manifesto who wants to transform my family to a species that he called omnivores.' Who would think that?" asked James, who confirmed the family has since left Hawaii altogether.

As for Zayas, after his arrest he was granted supervised release -- before getting arrested again for allegedly burglarizing a temple. While awaiting trial on burglary charges, he was accused of killing another inmate and charged with first-degree murder and second-degree murder in 2020 and is currently in a mental health facility awaiting trial.

New episodes of "Phrogging: Hider In My House" drop Mondays on Lifetime.

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Ezequiel Zayas: Where is Phrogging and Murder Suspect Now?

In September 2019, James and Brittany Campbell returned home from vacation to find someone else living at their home. In the days that followed, the couple found several disturbing things in their house and began to think the stranger, Ezequiel Zayas, had been living there for a long time. The first episode of Lifetime’s ‘ Phrogging: Hider in My House’ features the Campbells’ story as one of the two cases featured. So, if you’re wondering what happened to Ezequiel, here’s what we know.

Who is Ezequiel Zayas?

After a weeklong vacation, all the Campbells wanted to do was to return to the comfort of their home. But to their horror, they saw someone else living in their house in Honolulu, Hawaii. James said, “There is a man peeking through the door. He’s trying to hold it shut, and the man says, ‘this is not your house,’ just very calmly. I am just floored.” The authorities arrived soon after and arrested the man, Ezequiel Zayas, who had been wearing James’ clothes.

However, it didn’t stop there. Their house was in complete disarray, and notes found on their computers were weird and unsettling. According to their lawyer, “There are stuff that he was putting on the computer – different things that he was writing about that make you think, did he do anything to our food in the refrigerator? Was he planning on doing things to our home?”

The Campbells also noticed diary entries for each one in the family and felt he had been watching them for a long time. The notes also talked about converting the family from omnivores to “ezequiels.” Furthermore, there were references to conducting surgery on the Campbells. In another video, Ezequiel was seen sitting naked in Brittany’s chair. Eventually, the couple got a restraining order against him. While Ezequiel was arrested, his troubles didn’t end there.

Where is Ezequiel Zayas Today?

After being taken into custody at the Campbells’ home, Ezequiel was out on supervised release when he was arrested again for an incident at a Buddhist Study Center in Manoa, Hawaii. Then, at around 9 PM on August 31, 2020, a prison guard at the Oahu Community Correctional Center in Hawaii checked on an inmate-on-inmate assault. The corrections officer reported seeing Ezequiel punch a fellow inmate, Vance Grace, in the head multiple times.

After Vance dropped to the ground, Ezequiel allegedly stomped his head and refused to comply with orders to stand down. Eventually, additional officers were able to restrain him, but Vance was pronounced dead at a hospital later; he suffered a hematoma. Then 27 years old, Ezequiel was charged with first and second-degree murder.

The investigation also revealed that he was reported missing in Bridgeport, Connecticut, in August 2019, before his mother spoke to the authorities a few weeks later; she learned that her son was being treated in Honolulu and wanted to return to Connecticut. Ezequiel pleaded not guilty to the murder charges and was declared “unfit to proceed.” For now, he remains at the Hawaii State Hospital until the trial begins.

Read More: Where Are Madisyn Gidrey and Brittany Campbell Now?

Deep Digital Machines

The Omnivore Trials

Game idea/wip.

The Omnivore Trials: A Rehabilitation For Ratlike People

A spritual successor and meta-sequel to the 1995 video game 'Drowned God: Conspiracy of The Ages'

Short Horror Game

- Point & Click

- First Person Perspective

- 3D Renders but 2D navigation, etc

- Pre-rendered Backgrounds

- Inventory System

- Description/Investigation system

- Computer Interface

- Text Based (No voice acting)

- Cutscenes

- Animations

- Sound & Music

- Journals/Manifesto

- Floatation tanks as fast travel? Or to transition between worlds? Maybe he doesn't sleep in a bed? Possibly using an astrological chart in the darkness to pick where to fast travel to

- Some kind of item or puzzle related to translating and understanding ancient languages/scripts you encounter (Aramaic, Hebrew, Hieroglyphs, Coptic, Cuneiform, etc)? Before doing this - talking to angels for example will just show Hebrew text on screen and afterwards it'll be shown in English

Tools & Software

Midjourney

Stable Diffusion

Photography

Blender (3D Work)

Modo (Modeling)

Mixamo (Rigging)

Visionaire Studio (Game Engine)

Miro (Planning)

FMOD (Audio Implementation)

Ableton Live (Music)

------‐------

Overview You are Number 7. Ezekiel.

You are living in someone else's house.

You are an intruder.

Don't be detected. Avoid them at all costs. Don't leave evidence. You DO NOT exist.

This is YOUR house.

At first the player is not aware of the fact that you are the phrogger/home invader living in someone else’s home. Waking up in your ‘own’ bed like it was a normal day. The family to begin with aren’t present in the home and arrive back from a holiday to Ezekiel’s surprise and fear - having him hide from them as to not make his presence known. The player must have some suspicion that he is an unreliable narrator and that the family are the invaders. After their return - Ezekiel makes comments about the fact things have been moved around the house, food has been eaten, etc and is convinced he is sleepwalking or must have misremembered, etc. When on the family computer he closes their innocent tabs and slowly begins to search for more and more strange and unhinged things like ‘Gender Reassignment Surgery’ and ‘Where to buy a hospital gurney?’. Purporting that he may be a surgeon, in the medical field, etc at first but slowly creating doubt in the player. Ezekiel is receiving messages from a higher power and having visions revealing the 'Great Truth' about mankind's origin and history - everything you've known, it's all been a lie. These visions and dreams occur while sleeping in the attic of the House. Ezekiel visits The Garden of Eden/Paradise in which he is shown and gains ancient knowledge. A place of gnosis and learning. Beautiful, abstract, non-euclidean and alien; The player wanders around solving nonsensical puzzles, reading documents, being visited by angels and taking in the environment. You learn the 72 names of God and the explicit name of God ‘Shem ha-Mephorash' from the leaves of The Tree of Life. A Cherubim and flaming sword guard the entrance to The Garden. Ezekiel awakes to having written a manifesto called ‘Cosmetology & The Omnivore Trials: A Rehabilitation For Ratlike People’ which outlines his intentions and missions on Earth. He has no memory of doing so. Ezekiel plans on creating the sacred androgyny ‘Adam Kadmon’ from surgically stitching together various body parts from the family - he is convinced they are a subhuman species called ‘Omnivores’ and must be purified to inherit ‘The Great Truth’. They must be rehabilitated.

Ezekiel studies each invader as closely as he can while avoiding detection. Forming profiles for each family member and analysing them in their sleep. Build, find and create surgical equipment, sigils and relics to perform the ritual; Cleansing their lips with hot coals. Adorning them in magick spells and amulets. Lastly, painting The Tree of Life on Adam’s body. You will also develop the sequel to the video game 'Drowned God' called CULT on the family's computer at the end of each day before sleep. This is seen as a tool to be used for spreading the secrets of existence, providing the masses with a way to unlock ‘The Great Truth’…If they are worthy. Reshape yourself. Reshape now. Reshape history. Fake ‘Drowned God’ Sequel Plot (CULT) :

- You must challenge and elude the Men In Black to find the final and 4th relic 'The Ark of The Covenant'.

- Legion (Greys/Aliens) are coming.

- You have disobeyed Kether & Malchut. There will be consequences.

- Focused mainly around Area 51 Ezekiel eventually cannot tell the difference between what he created in CULT, his visions and reality. Thinking the game is sending him messages, even though he programmed the game and it’s based on fiction. He is then convinced his next mission is to find The Ark of The Covenant and reunite the other three Relics (Rod of Osiris, The Holy Grail and the Philosopher's Stone) mentioned in Drowned God. These relics hold the power to reshape the world as one sees fit and hold insurmountable power. This is only possible by finding The Ark in The Garden of Eden - Which cannot be visited in the waking world.

Ezekiel gets in contact with Edward Cayce (The psychic from Drowned God) through a chatroom online and he informs Ezekiel that he is being monitored by ‘The Men in Black’, ‘Kether’ and ‘Malchut’. He finds out that there are some individuals who lived before the fall of Atlantis known as ‘Lost Angels’ or ‘Nephilim’. Ezekiel is one of these individuals, Kether and Malchut also. There have existed 6 before him and so far, none have succeeded. The Nephilim are currently fighting a battle that will determine the fate of man and the universe - each has their own interpretations and agendas about what Paradise should be like when they finally return to it and these ideologies clash.

Sharing this information eventually leads to Cayce’s kidnapping/death without your knowing and the MIB start impersonating Cayce to try to find more out about Ezekiel, his intentions and location. Ezekiel figures out this is a trap and he is being lied to, fearful of the information he has shared by confiding in Cayce. This adds an urgency and paranoia to the game to finish your mission; as they might come for you next. Was this all real?

WIP: God’s Throne may be the last area in the game. Mirroring Ezekiel in the Tanakh’s vision of God and his Holy Angels (Cherubim, Seraphim and Ophanim). Will he die? Will he go mad? Will he reject the truth? Will he enter in peace and leave in peace? Or should there be some kind of body horror interfacing with Adam Kadmon, God’s Throne or The Ark of The Covenant which involves cutting off your own limbs and attaching them to something, like what Ezekiel did to the family to create Adam?

Possibly combine/crossover Operation Sunray plot points/themes into this? The Ark of Covenant being worshipped by a cult of rotting, burnt people who do not realise it is a source of radiation. They use it to cook food, keep warm, adorn themselves with radioactive dust and consider it a blessing - even as their hair falls out, skin falls off and limbs are destroyed.

An 'Orphan Source' they think is magical which they ingest to give them insight and powers.

Bleak Ending? Transcendent? Bizarre and unfulfilling?

Is Ezekiel the same character as who we play as in Drowned God?

Ezekiel finding the book 'The Diary of A Plagiarist' by Richard Horne aka Enroh Drahcir from 1846 in the Library of Alexandria?

Lipton weapon, Havana Syndrome and sonic harassment?

Possible exploration of Area 51, military temples (Contains artifacts from ruins of The Library of Alexandria) and underground bunkers through some kind of astral projection by Ezekiel through his computer screen and into the game CULT. Experiments with human flesh, machines of mutilation, weapons that spread disease and miasma and weapons that drive people mad with sound. The instruments of torture are indescribable, something Ezekiel does not have the science nor knowledge to explain. There are creatures here though, stored in vessels...That are NOT of this Earth.

------‐------

Environments

Two separate worlds to explore

- Eden/Paradise which takes the form of your dreams and visions. A place of gnosis and learning. Beautiful, abstract, non-euclidean and alien. Full of nonsensical puzzles, visitations of angels and pieces of manuscripts. Find the Ark of The Covenant.

- The house. A dark, foreboding place of bodily horror, fear, change and tribulations. Where you will cleanse the subhumans to make the sacred androgyny 'Adam Kadmon'. Performing surgery on the family and stitching their parts together. Cleansing their lips with hot coals. Adorning them in magick spells and amulets. You will also develop the sequel to 'Drowned God' CULT on the family's computer at the end of each day before sleep.

Eden/Pardes/Paradise

Divine Garden (Guarded by Cherubim & a flaming sword. Within the garden is a pillar of fire and smoke which Ezekiel must climb that extends to the higher Gan Eden)

Tree of Life (The leaves of the Tree adorned in the 72 names of God which will reveal the explicit name 'Shem ha-Mephorash')

Tree of Knowledge of Good and Evil

Primordial Waters (The ruins of Atlantis, the AI ran Earth Coincidence Control Office, Joint Analog Numerical Understanding System computer system & site of Atum's Blue Lotus)

The Ark of The Covenant (Some kind of highly radioactive fuel source? Some kind of explanation of why it kills so many people in holy scripture)

God's Throne (Domain of God's Throne/Chariot and the Cherubim, Seraphim and Ophanim)

The Attic (Once Ezekiel begins sleeping there it becomes more adorned with reliefs, relics, Occult symbols, etc as days pass)

Living Room

Basement (Where the rehabilitation of The Omnivores will take place and Adam Kadmon will be created. Notice the 'As Above, So Below' reference)

Underground Bunker

Military Temple (Contains the Library of Alexandria and/or The Akashic Records)

Character Names

- Ezekiel or 7 (Prophet from the Tanakh who has visions from god and sees the throne of god and his angels).

- Family (Names unknown to begin with, the mother is deaf)

- Sophia (Mother)

- Aster (Father)

- Rose (Daughter)

- Adam (Son)

- Edward Cayce

Manifesto name

- Cosmetology & The Omnivore Trials: A Rehabilitation For Ratlike People

Game Titles

- The Omnivore Trials: A Rehabilitation For Ratlike People

- Aion (Possible subtitle?)

- Aion: God of The Ages

(Only 'The Omnivore Trials' visible in logo. No subtitle)

- Drowned God - Both the game and the real story of Harry Horse

- Darkness Within: In Pursuit of Loath Nolder

- Bad Day On The Midway

- The Dark Eye

- Home invaders, stalkers and phroggers

- My experiences growing up

- Bible, Tanakh & Gnostic Gospels

- Zoroastrianism

- Mythology

- Conspiracy Theories

- Rosicrucianism

- Alchemy, Occult & Alternative History

- Kabbalah

- Carl Jung

- The Double

- Man In The Iron Mask

- House of Leaves

- Blue Velvet

- MyHouse.WAD

- Discover My Body

- Water Womb World

- Following

- One Hour Photo

- Silent Hill 4

- Xenogears

- Bloodborne/The Paleblood Hunt

- Stalker/Roadside Picnic

"As Above, So Below"

"Trust too deeply and you will know the wickedness in men's hearts"

"Man is a mortal god, god is an immortal man"

"The most important question anyone can ask is: What myth am I living?"

"I believe in God, only because I'm well educated"

"It's hard to tell whether the world we live in is either a reality or a dream."

”They say that the Earth will have to be destroyed twice, once by water, and this has already happened...In the future it will be destroyed for the second time by fire”

"Do I even exist? I don't feel like I'm here yet"

"I am a cosmonaut venturing into the unknown inner spaces of the unconscious. I bring back scattered fragments of the dream and try to weave some semblance of coherence"

"I don't think words make everything understandable"

"Slip Into The Supreme"

"Do not be afraid" (Most commonly spoken phrase in the bible when angels appear to humans)

Chapter 1: As Above

Osiris awoke, so that he might lead the Children of Man in the Garden, and took a wife, and they lay together in the Union of the Sun and the Moon.

And great was the Love that our Lord had for his wife, and called her Isis, that she may be the Moon, to stand at his right hand.

Then they made Man in their image, to give them dominion over the Garden, to live in peace with each other and the animals in a union of balance in both light and dark.

Four men entered pardes (Paradise/Eden) - Azzai, Zoma, Acher, and Akiba. Azzai looked into the Garden and died; Zoma looked and went mad; Acher apostatised and attempted to destroy the plants; Akiba entered in peace and departed in peace.

One law was made, that they might not touch or see the Tree of Life, the Kabbalah, for all the secrets in there would bring harm unto the children.

Then Horus came into the Garden, and saw that the Secret was safe, for the Firebird, The Rod, The Cup, and the Stone were not destroyed.

So he took up dominion over the Nephilim and taught them how to cut stone with light and turn water to fire.

When Horus heard that Osiris had taken a bride He was angered and cried out "Why hast thou so defiled thyself that thou might lie with an animal?"

Then Horus, for he is the Serpent, hid in the Garden that he might trick Isis.

When Isis was alone in the Garden, Horus came to her and said, Am I not fair to thee that I would show you the greatest of the secrets, the Tree of Life? Come and I will show thee.

And Isis answered not and was afraid, for she knew that the Serpent meant to harm her.

And when Horus found that Isis would not aid him betray Osiris, he plotted with his conspirators to kill Our Lord.

He took the firebird, the Rod, and slew him. This is the first Truth, and is the testimony of Baphomet.

And a great cry went up to Heaven, when it was learned that our Lord was dead, and would not walk in the Garden again.

Then, brother fell on brother and fought like beasts, and slew those they most loved, even their wives and children were not spared the sword. Much blood was spilt to his name, and the suffering was terrible, so great was their love for Osiris.

This is the last part of Genesis, the history of the people of Isis, the Nephilim, and the secret remains that Men have kept the identity of the goddess hidden, though her signs are everywhere, if you have eyes to see them.

Here ends the first Garden, though this paradise shall come again, for the world goes on forever.

"Climb the Tree of Life to Heaven Ten apples to the spiral stair. First the lodges, then the Realms, To Chesed, Binah, Din, and Chokmah. Judgement gives the Sun and the World. Where then, the hidden realms?”

Chapter 2: So Below

In the beginning existed only a great chaotic cosmic primordial ocean (Nun) before a Blue Lotus flower arose on the ocean floor. Seeded by the immaterial God of The Sky (Horus). The flower then blossomed - Emerging the self-created (Atum).

He was the first god of the material world, creator of himself. Seeing the nothingness around him, he determined to create a world. He had intercourse with himself, becoming pregnant and using his mouth as a womb. When he spat out his gestation, he created the twin god and goddess named Shu and Tefnut, siblings and lovers who shared a single soul.

There was still no light in the primordial darkness, and Atum could not find his children. He ripped out both his eyes in desperation and sent one to look for Shu and Tefnut - The other to Illuminate the darkness. Once his eyes and children returned to him and upon seeing his creations - He could not help but weep - Bringing life into being.

Due to his betrayal and slaying by his kin in his home province of the immaterial - Osiris decides to flee to the material world in opposition to both Horus and Isis - Which results in their great displeasure and eventual plans to kill their lord again; as they do not think humanity are worthy of inheriting Paradise and living in the second Garden.

Isis - God of the material and immaterial worlds. Said to be the most powerful of all gods, with the power to control fate itself.

Horus - God of the Sky, claims he is the last of his kind but this is not true. Son and creation of both Osiris and Isis. In opposition to Osiris and first to make contact with humanity after the Roswell incident. Made deals with The Majestic-12. The creator and/or ally of Legion - which appear to be artificial creations; as they have barcodes on their hands, are suffering with genetic disorders that worsen with time and are referred to as 'Automatons' by Baphomet. It's also possible the Horus gene was used to create them and they are a genetic hybrid - which would explain their insistence on continuing genetic experimentation on humans. Possibly seeking a solution to their inherited obsolescence.

Is Horus as malevolent as he seems?

Osiris - God of the dead, The Drowned God, a Non-Human Intelligence who fled his home of the immaterial, founding Atlantis on Earth and shepherding humanity before The Great Flood. Both husband and creation of Isis - His death and Exodus from the immaterial caused him to forget his origins and past. Bringing with him only the innate truth of humanity.

He took Isis as a wife on Earth in a holy union of the Sun and the Moon. He was eventually betrayed by her and Horus. Being drowned in a deluge, resurrected and imprisoned for eternity as The Drowned God. His 'death' resulted in the loss of The Great Truth in humanity's collective unconscious and cemented their fate to live in the realm of the material - losing their privilege to walk among God's and The Garden of Eden. Humanity spends their future relearning and uncovering what they have lost.

Is he truly as benevolent as he seems?

Atlantis is an AI ran base and representation of Paradise in the material world that non-human intelligence (Osiris) created. Inhabited by both primogenial humans and Gods alike. It was used for genetic experimentation by Horus and Legion without Osiris' knowledge. Horus creating the 'primitive' human race which would eventually make up the twelve tribes.

It was suddenly abandoned and eventually fell into ruin due to humans lacking the knowledge to operate and maintain it - This brought about a great flood orchestrated by Isis which drowned the great city and Osiris along with it - leaving it eternally forgotten.

After the deluge, the dominion of the sons of god was over and now the twelve tribes of humanity spread to the four corners of the world.

The Gnosis truly did not drown in the deluge though - they would find the AI (NOAH) ran biomechanical Ark which Osiris left for them to create their own life and what was left of Atlantis; Finding in their own DNA who created them and how. Humans would go on to conspire to hide this information for generations. Encoding it in art, writings, teachings to pass on the information to those worth of possessing such knowledge. Passed down from Atlantis to Egypt, down through the Twelve Tribes, from Moses to Solomon to the Shambala Monastery, to the Messiah and the Madonna, to the Holy Lodge of the Knights Templar, the Priory of Sion, the Rosy Cross, the Bavarian Illuminati, and the 33 levels of Freemasonry stored in the buried vaults of the Vatican.

Legion continued to experiment on humans throughout history without their consent.

The Kether Lodge (Fallen angels or Nephilim of the material world) worship Osiris with a heavy focus on technology, logic and patriarchies . Believes there are no conspiracies and the universe is only governed by Chaos. They desire to reshape Paradise and return to it. Most definitely malevolent.

The Malchut Lodge (Fallen angels or Nephilim of the immaterial world) worship Isis, exalting nature over technology and emphasise emotion over logic. They desire to reshape Paradise and return to it. Most definitely malevolent.

In 1945 the Vatican having recovered a UFO wreck during Mussolini's time in office and making a deal with the USA to have religion be kept in power and the USA being made to not disprove the existence of god by revealing the discovery of NHI - They would only hand over the ship if they maintained this disinformation for the entire foreseeable future. The Vatican would then maintain that none of this occurred in return and suppress the truth - Supporting the USAs agenda to keep the existence of UFOs and NHI a secret. This was the first recovery of an intact craft of exotic origin.

After the rapid escalation of knowledge of the existence of NHI due to the Vatican's UFO exotic craft recovery, the dead pilots recovered in The Roswell Incident, etc. Horus made contact with the MJ-12 and made perverse deals with them to assure mutual secrecy of both parties agendas - all the while allowing himself greater control and leverage.

During The Last Days, humanity will uncover the records of Atlantis in The Library of Alexandria and know that Solon did not lie in his account to Plato of the great primeval city that once existed in the Atlantic ocean.

And when the Four Creatures align (Leo, Taurus, Scorpio and Aries) the world will be covered by fire. Does this allude to a nuclear destruction caused by The Ark of The Covenant? Destruction or purification by God?

The events of 'Drowned God: Conspiracy of The Ages' unfold - Number 6 uncovers The Great Truth and succeeds in uniting three Relics (Rod of Osiris, Philosopher's Stone and Holy Grail) but ultimately fails to find the fourth and final relic, The Ark of The Covenant due to intervention by MJ-12. Number 6 meets 'The Relic Hunter' or Number 5 who also failed in his task. The only difference being he recovered only one relic but this happens to be The Ark but informs Number 6 it cannot be found in the material world. He ultimately gives up his material and immaterial body - Which allows Number 6 to inherit his findings and hopes he does the same; Allowing the possibility of the next reincarnation to uncover this wisdom. The next incarnation being Number 7. Ezekiel.

Music References:

Drowned God

Pathologic 1 & 2

Silent Hill

Fallout 1 & 2

Darkness Within

Planescape: Torment

Lovely Sweet Dream (LSD)

Thief 1, 2 & 3

Vampire The Masquerade: Bloodlines

Einstürzende Neubauten

Warp Records

The Residents

Dark ambient

Cursor References:

HUD References:

Puzzle Design & Ideas:

Music/sound based puzzle involving interfacing with the JANUS computer in the underwater ECCO base ran by AI. Through manipulation of symbols the system allows humans to communicate with underwater beings by converting it into ultrasonic or infrasonic signals which are played into the water. The same in reverse is also true. The player will be matching symbols to sounds and vice versa.

Adam Kadmon ritual puzzle involving arranging body parts, stitching them together and chopping them apart. Performing ritual magick by cleansing their lips with hot coals. Adorning them in magick spells, sigils and amulets. You will reference a visual guide of the Kabbalistic Tree of Life and your manuscript.

Alchemic puzzle involving making homemade tinctures to use on the family for transmutation and anaesthesia purposes.

In Alchemy there are three main elements called the three primes or 'Tria Prima' of which all material substances are made; Sulphur, Mercury and Salt. Sulphur represents the soul, Mercury the spirit and Salt the body. Mercury is the transitory element between Sulphur and Salt - The medium through which invisible and immaterial consciousness can be placed within the world and reside in matter.

Tree of life puzzle

Puzzle involving the textual exegesis PaRDeS (Paradise) system used for Kabbalistic interpretation of scripture

- Peshat (Literal and direct meaning) - Re'iah (Hints of deeper meaning) - Derash (Comparative meaning) - Sod (Esoteric or hidden meaning)

Visual References:

Garden of Eden

The Ark of The Covenant

The Tree of Life

Primordial Ocean

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A Phrogging Nightmare: An Unknown House Guest Planned Gruesome Surgeries for One Honolulu Family

He was going to turn them into perfect specimens.

Photo Credit: Dmitry Ant/Unsplash

Newlyweds James and Brittany Campbell and their two young children left their Honolulu home for a week to visit relatives on the U.S. mainland. When they returned on September 20th, 2019, it was clear that something was very, very wrong. James' bike was sitting outside in the driveway, but it had been safely tucked away when the family left.

Leaving his sons in the car, James approached the front door. When he tried to open it, he discovered a stranger inside pulling it closed. The intruder peeked through the crack in the door and very calmly informed James that "this is not your house."

The man inside, Ezequiel Zayas, was just one of many to commit the crime of 'phrogging'. This eerie crime occurs when a stranger finds their way into someone's home and secretly lives there for anywhere from days to months at a time. They could be in the attic, a cupboard, or even the walls. And unlike squatting, these perpetrators don't care if the residents are around.

And as terrifying as having an unwanted and unknown guest may be, the Campbell's story only gets worse.

11 Disturbing True Crime Stories You Can Read Tonight

While Brittany called the police , James armed himself with a sledgehammer and managed to get Zayas out of the house. In the front yard, the couple noticed that the intruder was wearing James' clothes. Zayas took this time to reassure the couple that he had taken care of their cat while they were away. This prompted Brittany to run inside and check on the animal, which she found locked in a cage with no water.

Once inside their home, it was an eerie scene. It appeared as though Zayas was doing an inventory of everything they owned. Pots and pans had been stacked on top of each other. All of James' musical equipment had been unpacked in the living room. Oddly enough, Zayas had left the children's rooms immaculate, doing their laundry and making their beds. However, the couple's bedroom was trashed.

Amidst the mess was one of their old laptops, a device Zayas had used to compile a disturbing diary about the Campbells. This featured details he had to have picked up from listening to their conversations , including the fact that Brittany and James were struggling to have a baby, and Brittany was undergoing fertility treatments. Zayas commented in his notes that Brittany should give up and simply focus on the children she already had.

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Keep it creepy.

Zayas' notes were titled "The Omnivore Trials: A rehabilitation of Ratlike people." The detailed observations tipped off the Campbells to the fact that this man had probably been living in their home for far longer than they could imagine. But the computer contained two more disturbing files. One was a video that Zayas had recorded as he sat naked in one of the Campbell's chairs. In the video, he appeared to mock Brittany in a twisted farce of a makeup tutorial.

The other document was far more disturbing. When Brittany noticed that several knives had been set out beside the old computer, she also uncovered a gruesome manifesto. Zayas had typed up horrifying plans for the family, which included surgeries to turn them into a species he called Omnivores. This included "sexual reconstruction" and "hand transplant" surgeries for Brittany and the two children. He had hoped to turn them into perfect people.

9 Creepy Stories That Remind Us Why We Have Locks on Our Doors

As horrific as all this was, they started to remember little oddities around the house over the past couple of months that began to make a lot more sense. In the middle of the night, a computer's webcam had turned on. Doors had been opened or unlocked that they were sure they had secured. The dog barked at what they thought was nothing. Boxes in the garage had been opened. Items in the house were out of place.

Once, James had even seen a person's shadow outside the house. He later came across a strange message left on a desk calendar: "Your rehabilitation starts today. Do as I did: Choose a house, clean it, set up all devices."

He had thought it was a message from his wife, asking him to tidy up around the house. But now James and Brittany knew that all the strange things that had been putting a strain on their home life had been the work of Zayas.

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Following his arrest, Zayas was charged with burglary and put out on supervised release. Not long after, he was arrested yet again for the alleged vandalization of a Buddhist temple. In 2020, while in a correctional facility for that offense, Zayas allegedly beat a fellow inmate to death. Charged with murder in the first and second degrees, Zayas pled not guilty.

Zayas was found to be "unfit to proceed." As of now, he is being kept at the Hawaii State Hospital until the trial begins.

As for the Campbells, their shocking run-in with Zayas has certainly left a traumatic mark. The family has moved out of their Honolulu house and left Hawaii altogether. Brittany has stated that the struggle for normalcy continues on.

Featured image: Dmitry Ant/ Unsplash

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Star Seeker

Couple Found Stranger Hiding In Their House Planning To Do Gender Reassignment & Amputation Surgeries On Them!

[Warning: Potentially Triggering Content]

This is about five of our worst nightmares wrapped into one.

On Monday, Lifetime kicked off its new show Phrogging: Hider In My House with a bang, with the family in the premiere episode telling the disturbing story of the time they caught a stranger hiding in their house — who was planning on surgically transforming them into a race of deformed beings he called “Omnivores.”

For those who don’t know, “phrogging” is the term for when people discover others secretly living in their homes — usually in places like walls, crawl spaces, and attics. And this particular story is a doozy…

James and Brittany Campbell recounted the terrifying story, which initially made headlines back in 2019. The couple explained that after getting married and moving to Honolulu with their two children that year, they started to notice things that weren’t adding up. The two discovered their possessions were moving around, their webcam was turning on at night, boxes had been opened in the garage, and Brittany heard the door slam “out of nowhere.”

Related: Law & Order Set Becomes REAL Crime Scene When Crew Member Is Mysteriously Shot Dead

Brittany said the whole ordeal left her “on the verge of a complete mental breakdown.”‘ But James, meanwhile, said he thought “she was being paranoid” and that he was “getting frustrated” with his wife, despite seeing some weird activity of his own. The patriarch remembered seeing the shadow of a person outside their home one day, then coming across a bizarre message left on a desk calendar, reading:

“Your rehabilitation starts today. Do as I did: Choose a house, clean it, set up all devices.”

James said he assumed his wife wrote it for him and wanted him to clean the house.

But they met the note’s real author in September 2019 after traveling to the mainland for a week. When they returned, they knew something was wrong when they noticed James’ bike was left in the driveway. Keeping the kids in the car, James opened the garage and “saw that it had just been completely trashed.”

James went to open the door to inspect more, but a man who was inside the home kept him from entering. Brittany said:

“It opens a crack and we can see a person inside our house.”

James added:

“There’s a man peeking through the door, he’s trying to hold it shut and the man says, ‘This is not your house,’ very calmly.”

James then made the startling realization that the stranger was wearing his clothes, which made him assume the man was homeless and on drugs. After the man told the couple he “took care of your cat” while they were gone, Brittany ran inside to check on their pet, and found the feline inside a cage, without water. To make matters even stranger, she said the home looked like he had been “doing an inventory” of everything inside.

Police arrived and arrested the man, who “was very casual” about the whole situation, according to the couple. Brittany added:

“It was really as if this person didn’t think he was doing anything out of the ordinary.”

After the man, identified in the press as Ezequiel Zayas at the time, was taken away, the couple continued to check around to see what he was up to. They discovered he had done all of their sons’ laundry, made their beds, and left the room “immaculate.” But when they got to their own bedroom, they found a disturbing scene.

In their bedroom, the couple found a towel set up with knives on it, next to a pair of their computers. One computer showed a text document titled:

“The Omnivore Trials: a rehabilitation for rat like people.”

The text also included “intimate details” about things the man “could have only known if he was listening to our private conversations,” the Campbells explained.

Brittany revealed:

“He somehow knew my husband and I were trying to have a baby. He wrote that I should give up on trying to have a baby and focus on the children that I have. This person had been watching us.”

But it gets worse… While speaking to The Post , Brittany said the stranger “wanted to play doctor on us — and not in the cute little kid way,” adding that he aimed to “make us into perfect people.” The two detailed the man’s sick plans on the episode, with James sharing:

“These writings were suggesting that surgical procedures should be performed on my wife and my children. We found these serums that are labeled to use on the ‘omnivores.’ He had been looking up videos on how to surgically remove an arm, he looked up how to do gender reassignment surgery.”

Brittany went on to say the man had also looked at websites to buy surgical tables, and researched how to perform certain surgeries at home. She explained:

“He had researched ways to implement these plans that he had.”

Brittany said another computer had a video on it of Zayas apparently “mocking” her, with footage showing him doing “like a makeup tutorial with a really bizarre twist on it.”

James summed up his thoughts on the whole disturbing scenario, telling viewers:

“There’s not even a single part of me that would have thought, ‘Hey, there’s a guy maybe in our attic writing a medical manifesto who wants to transform my family to a species that he called omnivores.’ Who would think that?”

We certainly wouldn’t!

The Campbells have since left Hawaii. Can’t say we blame them. We’d cross the country to get away from that memory, too!

Meanwhile, Zayas was — SHOCKINGLY — granted supervised release after his arrest. But he wound up getting arrested again for allegedly burglarizing a temple. While awaiting trial on the burglary charges, he allegedly killed another inmate; he was charged with first-degree murder and second-degree murder in 2020 and is currently awaiting trial in a mental health facility.

Take a look at just one clip from the show (below) for more of the couple’s unsettling experience with phrogging.

https://www.youtube.com/watch?v=y0EBaNTCJy0

[Image via Lifetime ]

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‘He wanted to play doctor on us’: Couple discover intruder actually living in their family home who planned to reconstruct their bodies

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The Campbells were not prepared for what they came home to (Picture: Lifetime/KHON2/Campbell family)

Most of us have never experienced the shock or terror of discovering a stranger has been living in our house without us knowing – but Brittany and James Campbell know exactly how it feels.

The couple – who feature in Lifetime’s true crime show Phrogging: Hider in My House – were away from their home in Honolulu with their two young sons for about a week, but got more than they bargained for when they returned.

On September 20, 2019, the family found a man inside their home and the situation just got scarier by the second.

Dad James, 36 – who is in the US Navy – grabbed a sledgehammer for protection, while Brittany, 37, called 911 for help, since ‘phrogging,’ is a crime.

Phrogging is when a stranger sneaks into someone’s space and secretly lives there for days, weeks or even months, with the crime series revealing all about the Campbell’s horrifying ordeal.

When cops arrived, the arrested the intruder – 23-year-old Ezequiel Zayas, who was standing in the couple’s front yard, wearing James’ clothes!

James and Brittany Campbell were newlyweds and living in a typical suburban community in Honolulu when a man allegedly lived in their home, observed them and detailed surgeries he wanted to perform on them in a journal. Their ordeal is featured in a new Lifetime show, ?Phrogging: Hider in My House.?

After he was taken away, the family believed that to be the end of it, but it became apparent that the nightmare had only just begun.

Upon daring to venture further inside their home, the Campbell’s found sheer chaos, with Brittany describing the scene as ‘just trashed’.

There were piles of pots and pans, James’ music equipment was all over the living room, and their bedroom was a mess.

Not only that, but their old laptop had been used to record disturbing diary entries about the family.

‘There [were] all these typed notes called The Omnivore Trials: A rehabilitation for Ratlike people,’ James told the show.

Brittany told The Post that it was at this point they realised the intruder had been in their home for a lot longer than they initially thought.

As events turned sinister, the stay-at-home mum noticed knives had been laid out next to the computer, along with a typed out ‘manifesto’ containing gruesome plans for the Campbells, such as ‘sexual reconstruction’ and a ‘hand transplant’.

She added: ‘He wanted to play doctor on us — and not in the cute little kid way. He wrote about how he could make us into perfect people.’

‘This guy had been sitting naked in my chair — that’s disgusting,’ she also says in the series, after finding a video he had made.

‘I just felt in terror.’

Suddenly, pennies started to drop as the couple began to make sense of incidents that were previously unexplainable.

For example, they had noticed a computer webcam turning on in the middle of the night over recent months, and doors being left open or unlocked.

Explaining phrogging, Jessica Everleth, the show’s executive producer, told The Post: ‘It starts out slowly — things go missing.’

She said victims are more likely to believe they are living with a ghost than a long-term trespasser: ‘You think it’s an urban myth, but it’s more common than you think.’

Following his arrest, Zayas was charged with burglary and was released.

Shortly after, he was arrested again for allegedly vandalising a Buddhist temple and, in 2020 it was alleged that he killed a fellow inmate.

He was charged with murder in the first and second degrees later that year, pleading not guilty.

Zayas was found to be ‘unfit to proceed’ and is now at the Hawaii State Hospital, where he awaits trial.

As for the Campbell family, they have since moved out of their Homolulu home and away from Hawaii.

They are still processing from the trauma, describing the incident as something that ‘has really affected us psychologically as a family’.

‘It’s uprooted our entire lives,’ Brittany says.

‘Recovering from this has been really difficult.’

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Phrogging: Hider in My House airs on Lifetime on July 18.

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Lydia Polgreen

The Strange Report Fueling the War on Trans Kids

An illustration shows a file labelled 'The Cass Review.' On top of it are two swings, one blue and one pink.

By Lydia Polgreen

Opinion Columnist

I n its upcoming term, the Supreme Court will once again hear a case that involves a highly contentious question that lies at the heart of personal liberty: Who should decide what medical care a person receives? Should it be patients and their families, supported by doctors and other clinicians, using guidelines developed by the leading experts in the field based on the most current scientific knowledge and treatment practice? Or does the Constitution permit lawmakers to place themselves, and courts, in the middle of some of the most complex and intimate decisions people will make in their lives?

The case, United States v. Skrmetti , has been brought by the Biden administration to challenge a ban in Tennessee on gender-affirming care for adolescents that all major American medical organizations support. Tennessee is one of some two dozen states that have passed laws limiting gender-affirming care for young people. The appeal argues that these bans are an unconstitutional form of sex discrimination: They forbid long-used treatments for transgender adolescents that are also given to children who are not transgender for different reasons.

The Tennessee law, called the Protecting Children From Gender Mutilation Act, prohibits the use of puberty-blocking medications for transgender adolescents, for example, but permits them for children who go into puberty at an early age. It bans the use of sex hormones like testosterone in transgender adolescents but allows it for other health issues, such as for children assigned male at birth. It bans gender-affirming surgeries for transgender adolescents — such surgeries are extremely rare — but allows similar surgical procedures that affirm the sex a child is assigned at birth, even on infants who are intersex.

The Supreme Court ruled in 2020 — somewhat surprisingly given its conservative majority — that differential treatment of transgender and gay people is impermissible under civil rights law. “It is impossible,” Justice Neil Gorsuch wrote in his decision in that landmark employment discrimination case, “to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Lawyers seeking to overturn gender-affirming-care bans will urge the court to follow the logic of that ruling and declare the Tennessee law and others like it unconstitutional.

Lawyers arguing in favor of these bans have taken a sharply different approach. In a striking echo of the arguments used to challenge medical abortion, they have asserted , against the consensus of the mainstream medical science, that the standard treatments for transgender children are not based in evidence and represent a grave risk to the health and well-being of young people.

This argument has been floating around conservative circles in the United States for some time, and some European government health care systems have embraced it, too, with some limiting access to gender-affirming care for young people, citing doubts about the evidence supporting it. The argument has been supercharged in recent months by an unlikely ally on the other side of the Atlantic Ocean: the British pediatrician Hilary Cass.

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Stages of Gender Reassignment

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

Lots More Information

Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

How Gender Identity Disorder Works
Is gender just a matter of choice?
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How fluid is gender?
Why do girls wear pink and boys wear blue?

Quality of Life Following Male-To-Female Sex Reassignment Surgery

Géraldine weinforth.

1 Department of Plastic Surgery and Hand Surgery, Universitätsspital Zürich

Richard Fakin

Pietro giovanoli, david garcia nuñez.

2 Department of Plastic, Reconstructive & Aesthetic Surgery and Hand Surgery, Center for Gender Variance, Universitätsspital Basel

Associated Data

Additional points regarding the study method

We conducted a systematic key word guided literature search of four databases (PubMed, EMBASE, Web of Science, PsycINFO) in March 2017 in order to identify the current medical literature relating to our research question. Among the search terms we used were “transsexualism”, “reassignment surgery”, and “quality of life” ( etable 1 ). The article search was adapted to the technical requirements (for example, the option of using MeSH terms) of each database and undertaken by GW and DGN independently, supported by the recommendations summarized in the PRISMA statement ( 16 ).

Inclusion criteria

We included only articles that focused on the topic of the quality of life of trans women who had had sex reassignment surgery, independently of the studies’ population sizes and publication dates. GW, RF, and DGN operationalized the search terms by using an iterative process following the PICO method ( e1 ) ( etable 1 ) and a search string was created with these ( eTabelle 2 ) . The search for publications intentionally identified only studies reported in English or German.

Exclusion criteria

Studies that did not exclusively focus on trans persons (for example, LGBT [= lesbian, gay, bisexual, and transgender] studies) or that did not evaluate quality of life by using a standardized questionnaire were not considered. Furthermore, this review did not include review articles, published dissertations, nor congress presentations/commentaries. Studies of trans persons who were under age were excluded too.

Screening process

During the study selection process we excluded according to the mentioned criteria those studies that were not able to contribute to answering our research question ( figure ). Furthermore, we searched the reference lists of all selected articles in order to be able to include further studies that were not found in the databases. This yielded four additional studies that met the inclusion criteria. In a parallel and independent process, DGN checked the results of this search. In cases where discrepancies were found, a solution pertaining to the inclusion of the relevant study was found by consensus.

Study analysis

After the study selection process we viewed full-text articles and collated important key study data ( table 1 ). According to the definitions in the PICO scheme ( e1 ) we collated all relevant parameters from the individual studies in further full-text reviews. The first author extracted the data, and DGN checked these in a second, independent process. All included articles are non-randomized studies of evidence level III ( e2 ). Some studies ( 17 – 21 ) reported on the quality of life of trans women as well as trans men. In these cases we ensured that the data evaluation for trans women was done separately or the ratio M–F/F–M was in favor of trans women. Where information was lacking or lack of clarity existed in individual studies, we contacted the authors. Table 2 shows the quality characteristics of the included studies.

The prevalence of persons who are born with primary and secondary male sexual characteristics but feel that they are female (trans women) is ca. 5.48 per 100 000 males in Germany. In this article, we provide a detailed overview of the currently available data on quality of life after male-to-female sex reassignment surgery.

This review is based on publications retrieved by a systematic literature search that was carried out in the PubMed, EMBASE, Web of Science, and PsycINFO databases in March 2017.

The 13 articles (11 quantitative and 2 mixed quantitative/qualitative studies) that were found to be suitable for inclusion in this review contained information on 1101 study participants. The number of trans women in each study ranged from 3 to 247. Their mean age was 39.9 years (range: 18–76). Seven different questionnaires were used to assess postoperative quality of life. The findings of the studies permit the conclusion that sex reassignment surgery beneficially affects emotional well-being, sexuality, and quality of life in general. In other categories (e.g., “freedom from pain”, “fitness”, and “energy”), some of the studies revealed worsening after the operation. All of the studies were judged to be at moderate to high risk of bias. The drop-out rates, insofar as they were given, ranged from 12% to 77% (median: 56%).

Current studies indicate that quality of life improves after sex reassignment surgery. The available studies are heterogeneous in design. In the future, prospective studies with standardized methods of assessing quality of life and with longer follow-up times would be desirable.

The term “gender incongruence” (GI) describes the situation in which a person does not identify with the gender they were assigned at birth on the basis of physical sexual characteristics and that they consequently experience “a marked and persistent incongruence between. .. experienced gender and the assigned sex” ( 1 ). The term trans women describes persons with congenital primary and secondary male sexual characteristics (assigned male at birth) who feel/identify as women. Trans men are persons who feel/identify as men but who have primary and secondary female sexual characteristics (assigned female at birth). Persons who fully identify with the sex/gender they were assigned at birth are known as cis women and cis men.

A data analysis from 2000 showed a prevalence in Germany of 4.26 trans persons/100 000 population (5.48 trans women/100 000 of the male population and 3.12 trans men/100 000 of the female population) ( 2 ). We are not aware of any more recent data for Germany.

If persons with gender incongruence develop clinically relevant biopsychosocial suffering, they have gender dysphoria (GD), according to the DSM-5 classification ( 3 ). For many trans persons, physical transition is the best option for alleviating the symptoms of gender dysphoria ( 4 ). Sex/gender reassignment hormone treatment as well as surgery have a central role in this setting ( 5 ). The latter comprise surgical procedures involving the genitals (sex reassignment surgery) ( box ), the breasts, and the face and vocal cords, as well as hair epilation ( 6 ).

Principle of male-to-female sex reassignment surgery

Bilateral orchiectomy
Preparation of the glans (head) of the penis with the complete neurovascular bundle
Preparation of the urethra
Subtotal resection of the cavernous bodies (corpora cavernosa) and the corpus spongiosum of the penis
Preparation of the neovaginal space in the perineal area between rectum and urethra/bladder
Penile inversion vaginoplasty (pedicle flap from the skin of the penal shaft: gold standard)
If required, use of free split-thickness skin grafts
In selected cases, this is the primary indication—for example, in trans women with penoscrotal hypoplasia or at the patient’s wish (for better natural secretion).
This procedure can also be used as a secondary intervention in patients after unsatisfactory penile inversion vaginoplasty.
Construction of a neo-clitoris from the glans (head) of the penis
Construction of a urethral neo-meatus after urethral shortening as required
Construction of labia from the remaining scrotal skin, possibly also labia minora

A US study showed that from 2000 to 2011, the rate of surgical sex reassignment measures among trans persons rose from 72% to 83.9% ( 7 ). These data move the question of the effectiveness of such operations increasingly into the focus of clinical attention and awareness ( 8 – 11 ).

In the context of evidence-based medicine, the consensus is now that the success of medical procedures should not be studied merely in terms of objective results (survival and complication rates, measurements of functionality, etc), but that patients’ personal wellbeing should be included in assessing the success of any procedure ( 12 , 13 ). Review articles to date have shown that sex reassignment hormone treatment has a positive effect on the quality of life of trans persons ( 14 , 15 ). By contrast, an overall assessment of quality of life after sex reassignment surgery is so far lacking. In this article we will attempt to provide a review of current studies, and on this basis we will investigate the question of quality of life after sex reassignment surgery.

For the review to be as representative as possible, this article deals with trans women only, whose incidence is notably higher than that of trans men (0.41 male to female/100 000 total male population in Germany and 0.26 female to male/100 000 total female population in Germany) ( 2 ).

We conducted as systematic literature search in PubMed, EMBASE, Web of Science, and PsycINFO in March 2017. GW and DGN independently undertook the article search on the basis of the recommendations summarized in the PRISMA statement ( 16 ). Details of the methods are described in the eMethods section.

We included only articles on the subject of the quality of life of trans women after sex reassignment surgery. GW, RF, and DGN operationalized ( etable 1 ) the search terms in an iterative process according to the PICO method ( e1 ) and set out a search string ( etable 2 ).

	transsexualism, transgender, transgenderism, gender identity disorder, transgender persons, sexual transition, gender transition, male-to-female, gender non-conform, gender-transform, gender incongruence
	reassignment surgery, sex reassignment, sex reassignment surgery, sex change, gender reassignment surgery, sex reassignment operation, gender transformation operation, penile inversion vaginoplasty
	–
	quality of life

* Key words used in accordance with the PI(C)O method

	“transsexualism” OR “transgender” OR “transgenderism” AND (“reassignment surgery” OR “sex reassignment”) AND “quality of life”
	(DE “Transgender” OR DE “Transsexualism” OR DE “Gender Identity Disorder”) AND (DE “Sex Change” OR DE “Surgery” OR “reassignment surgery” OR “sex reassignment”) AND “quality of life”
	(“Transsexualism”[Mesh]) AND (“Sex Reassignment Surgery”[Mesh]) AND (“Quality of Life”[Mesh]) ((“Transgender Persons”[Mesh]) OR “Transsexualism”[Mesh]) AND (“Quality of Life”[Mesh]) (“Quality of life”) AND (“gender reassignment surgery” OR “sex reassignment operation” OR “gender transformation operation” OR “sex reassignment surgery” OR “penile inversion vaginoplasty” AND sex* AND chang* OR sex* AND reassign* OR gender-reassign) AND (gender-dysphor OR transsex* OR gender-nonconform* OR gender-non-conform* OR transgend* OR transident* OR gender-incongruence OR gender-varian* OR gender-transform* OR gender-identity-disorder* OR sexual-transition OR gender-transition OR sexual-dysphor* OR transvest* OR autogyn* OR trans-sex* OR trans-gend* OR trans-ident* OR “male-to-female”)
	(gender-dysphor* OR transsex* OR gender-nonconform* OR gender-non-conform* OR trans-gend* OR trans-ident* OR gender-incongruence OR gender-varian* OR gender-transform* OR gender-identity-disorder* OR sexual-transition OR gender-transition OR sexual-dysphor* OR transvest* OR autogyn* OR trans-sex* OR trans-gend* OR trans-ident* OR “male-to-female”) AND (“gender reassignment surgery” OR “sex reassignment operation” OR “gender transformation operation” OR “sex reassignment surgery” OR “penile inversion vaginoplasty” OR sex* chang* OR sex* reassign* OR gender-reassign*) AND (“quality of life”)

* Catch phrases and key words used in the literature search

Among others, we excluded studies that did not focus exclusively on trans persons or that didn’t collect data on quality of life by using a standardized questionnaire. We also excluded studies in underage trans people.

The Figure shows the study selection process.

An external file that holds a picture, illustration, etc.
Object name is Dtsch_Arztebl_Int-116_0253_001.jpg

Flow chart illustrating the study selection process

All included articles are non-randomized studies with an evidence level of III ( e2 ). In the case of studies that reported on the quality of life of trans women as well as trans men ( 17 – 21 ) we ensured that the data for trans women were evaluated separately or that the ratio of M–F/F–M favored trans women. Table 1 shows further key study data; Table 2 shows the quality characteristics of the studies.


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* 1 Numbers of study participants after removal of dropouts ( table 2 ); exception: Lindqvist et al. ( 23 ), see Table 2

* 2 M–F, male-to-female; F–M, female to male, sex reassignment surgery

				)
Ainsworth et al. ( )	—	—	n = 25 (10.12%) M–F* had sex reassignment surgery n = 47 (19.02%) had sex reassignment surgery and facial feminization surgery n = 28 (11.3%) had facial feminization surgery n = 147 (59.51%) had no surgery Time of survey not stated, hormone therapy	Moderate to high: selection bias, classification bias, bias owing to deviations in interventions
Bouman et al. ( )	20.51%	Non-respondents n = 6 (15.38%) Lost to follow-up n = 1 (2.56%) Deceased n = 1 (2.56%)	27 M–F (= 87.1%) completed the QoL questionnaire, hormone therapy	Moderate to high: selection bias
Cardoso da Silva et al. ( )*	75.26%* (n= 30 M–F [15.7%] excluded)	—	Dropout rate very high, no reasons given 31 M–F (65.95%) had corrective surgery, hormone therapy	Moderate to high: selection bias, attrition bias
Castellano et al. ( )	11.76%	Non-respondents n= 8 (11.76%)	Only the domain general quality of life score and subdomains ‧sexuality and body were requested, hormone therapy	Moderate to high: selection bias Moderate: detection bias
Jokic-Begic et al. ( )	25%	Lost to follow-up n = 1 (12.5%) Refused participation n = 1 (12.5%)	Very small study population, socioeconomic and clinical circumstances, psychotherapy, hormone therapy	Moderate to high: selection bias
Kuhn et al. ( )	—	—	No detail on interventions in the control group,no separate data analysis for M–F and F–M, hormone therapy	Moderate to high: selection bias, bias owing to deviations in interventions
Lindqvist et al. ( )*	77.37%*	Deceased or moved without changing address and entry in residents‘ register	Very high dropout rate, only 17 patients completed the questionnaire at all 4 follow-up points, hormone therapy	Moderate to high: selection bias, attrition bias
Papadopulos et al. ( )	61.15%	Unavailable/incorrect phone number n = 38 (31.40%) Refused participation n = 14 (11.57%) Quesionnaire not completed n = 22 (18.18%)	Inclusion criteria: only patients who had had corrective surgery or those who did not require such surgery, hormone therapy	Moderate to high: selection bias
Parola et al. ( )	—	—	Hormone therapy	Moderate to high: selection bias
van der Sluis et al. ( )	62.5%	Non-respondents n = 6 (25%) Lost to follow-up n = 3 (12.5%) Deceased n = 5 (20.84%) Refused participation n = 1 (4.16%)	Small study population Secondary vaginoplasty Hormone therapy	Moderate to high: selection bias
Weyers et al. ( )	28.57%	Non-respondents n= 17 (24.29%) Refused participation n=3 (4.29%)	Hormone therapy	Moderate to high: selection bias
Yang et al. ( )	—	—	n = 73 (34.92%) had facial feminization surgery n = 43 (20.57%) had breast augmentation surgery Only n = 4 (1.91%) had sex reassignment surgery Socioeconomic and clinical circumstances Hormone therapy in only n = 37 (17.7%)	Moderate to high: selection bias, bias owing to deviations in interventions
Zimmermann et al. ( )	55.56%	Non-respondents n = 45 (50%) Incomplete questionnaire n = 3 (3.34%) Inclusion criteria not met n = 2 (2.23%)	Absolute values from FLZ questionnaire not shown, only p-values reported, no separate evaluation of FLZ questionnaire for F–M and M–F, hormone therapy	Moderate to high: selection bias

* 1 M–F male to female; F–M female to male, reassignment surgery

* 2 Prospective study design

* 3 Of originally 190 participants, n = 160 (84.21%) completed the questionnaire preoperatively and n = 47 (24.73%) postoperatively

* 4 Out of a total of 190 study participants, n = 146 (76.84%) completed the questionnaire preoperatively, n = 108 (56.84%) 1 year postoperatively, n = 64 (33.68%) 3 years postoperatively, and n = 43 (22,63%) 5 years postoperatively. Most of the 190 participants completed the questionnaire at least at two follow-up points.

The studies made use of the following instruments:

6 studies used the Short Form 36 Health Survey (SF-36) ( 18 , 20 , 22 – 25 );
2 studies used the World Health Organization’s Quality of Life 100 questionnaire (WHOQOL-100) ( 17 , 26 );
2 studies used the Subjective Happiness Scale (SHS) in combination with the Satisfaction with Life Scale (SWLS) and the Cantrils Ladder of Life Scale (CLLS) ( 27 , 28 );
2 studies used the FLZ questionnaire ( Fragebogen zur Lebenszufriedenheit ) ( 21 , 29 ); and
1 study used the King’s Health Questionnaire (KHQ) ( 19 ).

None of the questionnaires constitutes an investigative tool that is specifically tailored to trans persons. Table 3 shows the result scales. Table 2 shows the confounding variables and, as far as it is possible to assess this, the risk of bias.


SF-36 ( , , – )	36 items	0	100
WHOQOL-100 ( , )	100 items	0	100
SHS ( – )	VAS, 4 items on a 7 point Likert scale	4	28
SWLS ( – )	VAS, 5 items on a 7 point Likert scale	5	35
CLLS ( – )	VAS, short scale (L-1)	0	10

*For the studies referenced in parentheses, it was not possible to calculate effect sizes

Quality of life

The SF-36 and WHOQOL-100 are validated, reliable and disease–non-specific instruments for measuring health-related quality of life ( 30 , 31 ). They can be used to gain information on the individual health status and allow for observing disease-related stresses over time. The questionnaires collect data on numerous aspects of daily life, which in their totality reflect quality of life. They are used internationally and therefore make cross-cultural studies an option ( 32 ).

Studies that used the SF-36 to answer the question of postoperative quality of life ( 18 , 20 , 22 – 25 ) observed after sex reassignment surgery an improvement in “social functioning”, “physical” and “emotional role functioning”, “general health perceptions”, “vitality”, and “mental health” (p = 0.025 to p >0.05). In two of these studies ( 22 , 24 ), “mental health” in trans women after sex reassignment surgery did not differ significantly from the standard sample. This explains the formally non-significant result. Ainsworth and Spiegel ( 22 ) showed that trans women without surgical intervention when compared indirectly with cis women from the SF-36 standard sample reported significantly poorer “mental health” (39.5 vs 48.9; p <0.05). Lindqvist et al. ( 23 ) and Weyers et al. ( 24 ) found an improvement in “self-perceived health” in the first postoperative year (p <0.05 and p <0.009), which deteriorated later but did not fall as low as its original score (p <0.0001). Furthermore, the studies concluded that “physical pain” increased postoperatively and “physical functioning” decreased; the postoperative follow-up periods varied between 3 months ( 18 ) and 5 years ( 23 ). According to Lindqvist et al. ( 23 ), “physical pain” in trans women five years postoperatively was comparable to that in the standard population (72.5 vs 72.7; SD 26.5).

Studies that used the WHOQOL-100 came up with the following results: Cardoso da Silva et al. ( 26 ) observed postoperatively an increase in “sexual activity” (p = 0.000) compared with the preoperative evaluation (prospective study design). Furthermore they found a postoperative improvement in the “psychological domain” (p = 0.041) and “social relationships” (p = 0.007), but a deterioration in “physical health” (p = 0.002) and “independence” (p = 0.031). Accordingly, deteriorations were seen in the areas of “energy” and “fatigue”, “sleep”, “negative feelings”, “mobility”, and “activities of daily living” (p <0.05). Castellano et al. ( 17 ) found after sex reassignment surgery for the group of trans women compared with the group of cis women no significant differences relating to “sexual activity” (65.85 vs 66.28; p >0.05), “body image” (64.64 vs 65.47; p >0.05), and the “quality of life score” (67.87 vs 69.49; p >0.05).

Quality of life and urinary incontinence

The King’s Health Questionnaire (KHQ) is a validated questionnaire for evaluating the impact of urinary incontinence on quality of life ( 33 ), a topic of central importance for trans persons ( 34 ). This questionnaire interrogates the quality of life domains always in association with urinary incontinence as the main problem. Kuhn et al. ( 19 ) showed that “general health” in trans persons was experienced as poorer to a relevant extent (Cohen’s d = 4.126; p = 0.019), and “physical” (d = -7.972; p <0.0001) and “personal limitations” (d = -7.016; p <0.001) were experienced to a greater extent. In contrast to this, trans persons felt less limited in terms of “role limitation” (d = 3.311; p = 0.046). For “emotions”, “sleep”, “incontinence”, and “symptom severity”, the differences to the control group did not reach significance. The control group consisted of cis women who had undergone abdominopelvic surgery. The evaluation of the visual analogue scale (VAS) showed a lower (d = 14.136; p <0.0001) degree of general life satisfaction in the group of trans persons.

Life satisfaction

The SHS ( 35 ), SWLS ( 36 ), and CLLS ( 37 ) are validated and internationally used visual analogue scales to evaluate life satisfaction. The SHS evaluates individual happiness and associated physical, mental, and social wellbeing ( 35 ). The SWLS was used as a short-form scale in the cited studies (also known as L-1) and included only the question on general life satisfaction ( 36 ). The CLLS evaluates emotional wellbeing associated with life satisfaction as well as subjective health ( 37 ).

Studies that used the SHS, SWLS, and CLLS ( 27 , 28 ) to evaluate postoperative life satisfaction reported a high degree of “subjective happiness” (5.6; SD 1.4 and 5.9; SD 0.6), of “satisfaction with life“ (27.7; SD 5.8 and 27.1; SD 2.1) and “subjective wellbeing” (8.0 [range: 4–10] and 7.9; SD 0.7) in trans women after intestinal vaginoplasty. The studies cited earlier differ with regard to the following items: Bouman et al. ( 27 ) studied a population of young trans women (mean age: 19.1 years) with penoscrotal hypoplasia after primary laparoscopic intestinal vaginoplasty. The study participants had received puberty blockers during their transition therapy, which resulted in penoscrotal hypoplasia and made penile inversion vaginoplasty ( box ) impossible. Van der Sluis et al. ( 28 ) studied an older population (mean age: 58 years) of trans women after secondary intestinal vaginoplasty—that is, patients who required secondary intestinal reconstruction owing to vaginal stenosis or insufficient vaginal length after penile inversion vaginoplasty. The postoperative follow-up period varied between 1–7.5 years ( 27 ) and 17.2–34.3 years ( 28 ). In spite of the different patient populations, these studies found that sex reassignment surgery had a positive effect on life satisfaction.

The FLZ is a validated multidimensional questionnaire for evaluating individual general life satisfaction ( 38 ). It is used in life quality and rehabilitation research and enables the recording of changes if administered repeatedly. It is available in a German language version only; for this reason, its results apply only to German speaking populations.

Studies that used the FLZ questionnaire ( 21 , 29 ) found that the postoperative life satisfaction of trans women in terms of “health” does not differ from that of the general population. Additionally, Papadopoulos et al. ( 29 ) found no differences for “friends”, “hobbies”, “income”, “work”, and “relationship.” A subanalysis of the module “health” found postoperatively in both studies a relevant decrease in “fitness” (d = 0.521; p <0.001) and “energy” (d = 0.494; p <0.003). Zimmerman et al. ( 21 ) additionally found a significant decrease in “ability to relax/equilibrium” (p = 0.002), “fearlessness/absence of anxiety” (p = 0.015), and “absence of discomfort/pain” (p = 0.037). Both studies ( 21 , 29 ) were retrospective surveys that were undertaken once only in a time period between 6 months and 58 months postoperatively. Papadopoulos et al. ( 29 ) included only subjects into the study who did not require any further corrective surgery after sex reassignment surgery or who had already undergone a second procedure for the purpose of minor corrections.

Two prospective studies documented postoperatively a notable improvement in quality of life ( 23 , 26 ). Four studies found that the life quality of trans women after sex reassignment surgery was no different from that of cis women ( 17 , 20 , 22 , 24 ). Sex reassignment surgery has also been shown to have a positive effect on life satisfaction ( 27 , 28 )—the exception was urinary incontinence, in which case life satisfaction dropped ( 19 ). Lindqvist et al. ( 23 ) and Weyers et al. ( 24 ) observed an improvement in self-perceived health in the first postoperative year, which then drops, albeit not all the way down to its original level. This is consistent with the honeymoon phase described by De Cuypere et al. ( 39 ), which has been described as a euphoric period in the first year after surgery. Several studies ( 18 , 20 – 25 ) showed that physical pain increased after surgery and physical functioning deteriorated. This is easily explained by the surgery itself, however; the postoperative follow-up periods in these studies varied between 3 months ( 18 ) and 5 years ( 23 ).

Altogether the study results imply that sex reassignment surgery has an overall positive effect on partial aspects, such as mental health, sexuality, life satisfaction, and quality of life.

These results were confirmed by Barone et al. ( 40 ) and Murad et al. ( 15 ) in their review articles, which were published in 2017 and 2010, respectively. Barone et al. ( 40 ) in a systematic review evaluated patient reported results after sex reassignment surgery; among others, regarding life satisfaction. Murad et al. ( 15 ) in a meta-analysis focused on quality of life and psychosocial health after hormone therapy (main aspect) and sex reassignment surgery. In sum, both studies found improvements in quality of life and life satisfaction after sex reassignment surgery, and an improvement at the psychosocial level. Hess et al. ( 11 ) concluded that the study participants benefited from sex reassignment surgery—they too found high rates of satisfaction postoperatively in Germany.

As sex reassignment surgery often constitutes the final step of sex reassignment measures, hormone therapy as well as accompanying psychotherapy may have had a confounding effect. Not all studies adjusted for confounding factors. A lack of randomization and control or the use of a matched control group ( 17 , 19 ) in the studies also introduced methodological bias ( table 2 ). Furthermore, the high dropout rates of 12% ( 17 ) to 77% ( 23 ) (median: 56%), which are mainly due to non-respondents, should be assessed critically. In our experience, however, the patient population of trans women is often reticent and is not interested in study participation because of personal reasons (“to not be reminded of that time”). Other authors have shared this observation ( 18 , 24 ), which may also explain the occasionally high dropout rates. There is also the possibility that dissatisfied patients were among the dropouts. Owing to socioeconomic and clinical conditions, the studies from Croatia ( 18 ) and China ( 25 ) need to be evaluated separately. On the one hand, the authors of both studies draw attention to the public’s lack of awareness and understanding (and the associated psychological stress for trans women) in these countries, and, on the other hand, statutory sickness funds did not cover the costs of all treatments, which were therefore accessible to only few patients. This explains the notably lower participant numbers of 3 ( 18 ) and 4 ( 25 ) male-to-female transitions after sex reassignment surgery. None of the included studies reported potential suicide rates.

The strength of this review lies in the fact that we included only studies that used standardized questionnaires. Tests (such as the SF-36 or WHOQOL-100) represent validated and reliable measuring instruments, for some of which reference standard populations exist, and they enable international and intercultural comparison. Furthermore, standardized questionnaires have the advantage of a high degree of objectivity in terms of conducting, evaluating, and interpreting studies.

The available study data show that sex reassignment surgery has a positive effect on partial aspects—such as mental health/wellbeing, sexuality, and life satisfaction—as well as on quality of life overall.

It should be noted that the studies are almost exclusively retrospective analyses of mostly uncontrolled and small cohorts, for which no valid or specific measuring instruments are available to date. Because of the high dropout and non-response rates, the current data should be interpreted with caution.

In spite of the essentially positive results, the data are not satisfactory at this point in time. Due to the studies’ limited follow-up times, no conclusions can be drawn as yet about the long term consequences of such procedures. Furthermore, many studies did not use standardized questionnaires and/or scores, which makes comparisons between individual studies difficult.

Key messages

Trans persons suffer from the tension between their biologically characterized body and their experienced sex/gender.
Undergoing medical and/or social transition seems for many trans persons the best possible solution for alleviating their gender dysphoria symptoms.
Results from studies imply that sex reassignment surgery on the one hand has positive effects in terms of partial aspects of quality of life, such as mental health, sexuality, and life satisfaction, and, on the other hand, on quality of life overall.
Because of the studies’ high dropout rates (12–77%; median 56%), the results should be interpreted with caution.
The studies did not include information on potential suicide rates.

Supplementary Material

Acknowledgments.

Translated from the original German by Birte Twisselmann, PhD.

Conflict of interest statement

The authors declare that no conflict of interest exists.

Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy

Transgender people experience distress due to gender incongruence (i.e., a discrepancy between their gender identity and sex assigned at birth). Gender-affirming hormone treatment (GAHT) is a part of gender reassignment treatment. The therapeutic goals of the treatment are to develop the physical characteristics of the affirmed gender as far as possible. Guidelines have been developed for GAHT, which recommend dosage as well as different formulations of oestrogen and testosterone for treatment. Questions arise about the metabolic side effects of hormone treatment. Establishing reference ranges for common analytes in transgender individuals remains a task for laboratory medicine. It has been suggested once GAHT is commenced, the reference ranges for affirmed gender are reported for red blood cells, haemoglobin and haematocrit. For transgender assigned-female-at-birth (AFAB) people, testosterone concentrations are recommended to be within the reference interval established for cisgender men and for transgender assigned-male-at-birth (AMAB) people, estradiol concentrations are within the reference range for cisgender women. Sex-specific reference ranges are available for certain laboratory tests, and these may be organ (e.g., heart)-specific. Transgender-specific reference ranges may be a requirement for such tests. Laboratories may need to make decisions on how to report other tests in the transgender population, e.g., eGFR. Interpretation of further tests (e.g., reproductive hormones) can be individualized depending on clinical information. Electronic medical record systems require fields for gender identity/biological sex at birth so that laboratory results can be flagged appropriately. In this review, we aim to summarise the current position of the role of the laboratory in the clinical care of the transgender individual. Prior to the review, we will summarise the genetics of sex determination, the aetiology of gender incongruence, and the recommendations for GAHT and monitoring for the transgender population.

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Puberty Blockers: A Review of GnRH Analogues in Transgender Youth

By Mitzi | First published January 30, 2022 | Last modified January 31, 2022

Abstract / TL;DR

Puberty blockers are medications used to pause puberty in both cisgender and transgender youth. For the latter, significant evidence suggests that they improve well-being, psychological functioning, and risk of suicidality, both during puberty and in later life. Their effects are reversible upon discontinuation. Current evidence does not suggest any negative impact on cognitive development, IQ, or fertility. A minor impact on bone density may exist, affecting primarily transgender girls, but little high quality data is available. Based on limited data, prescribers may wish to consider calcium supplementation in transgender teens receiving puberty blockers, and may wish to prefer transdermal delivery over oral estrogens in transgender girls starting hormone therapy in order to optimise bone density outcomes. There is a lack of evidence supporting the common belief that most children grow out of gender dysphoria (“desistance”), as widely cited data describing the rate at which this happens appears highly unreliable. Puberty blockers are difficult to access, and many Western countries have sharply restricted their use recently, in a trend condemned by numerous medical associations. Randomised controlled trials on puberty blockers can likely never be performed, but nonetheless, there is clear evidence they offer significant benefit, and have relatively minor risks.

Introduction

Puberty blockers, also known as gonadotropin-releasing hormone (GnRH) analogues , were introduced for medical use in the 1980s ( Swerdloff & Heber, 1983 ). Originally developed to supersede other therapies in the treatment of prostate cancer, they were soon adapted for paediatric use, revolutionising the treatment of precocious puberty : a rare condition in which puberty begins before the age of 8 (in natal girls) or 9 (in natal boys). Precocious puberty is associated with several negative consequences, such as short stature, teasing, bullying, and worse mental health outcomes. By reversibly pausing puberty for several years in children with this condition, outcomes are often significantly improved, and puberty blockers remain the mainstay treatment for this condition several decades later.

In the 1990s, puberty blockers began to be used in transgender adolescents, as a way of pausing their unwanted puberty, and giving them more time to consider their future ( Cohen-Kettenis & van Goozen, 1998 ). The protocol for this, originally develped by the Dutch VUmc clinic , has sometimes been referred to as the “Dutch Method.” Cohen-Kettenis et al. (2011) published a study following one such Dutch patient 22 years later. Since then, the use of puberty blockers has increased tremendously with the increase in patients seeking transgender healthcare.

Recently, puberty blockers have been the subject of controversy, with legal proceedings seeking to prohibit their use across several countries. Notably, their use was temporarily stopped in the United Kingdom in December 2020 following a ruling in the Bell v. Tavistock case, which was appealed in 2021. Also in 2021, Arkansas became the first U.S. state to make it illegal for doctors to prescribe puberty blockers, with several other states pursuing similar legislation. Critics express concern about the safety of puberty blockers, their reversibility, and effectiveness.

This article seeks to review the literature on the use and safety of puberty blockers in transgender youth, examining their safety, and arguments for and against their use in a comprehensive way. While rarely, alternative medications like the progestin medroxyprogesterone acetate have been used for this, this article mainly focuses on GnRH agonists : by far the most widely used class of medication for puberty blockade, and what’s most commonly colloquially referred to as “puberty blockers.”

Mechanism of Action

GnRH is a naturally occurring hormone in humans responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland . Through this mechanism, the body produces its gonadal estrogen and testosterone. GnRH agonists bind to the GnRH receptor and activate it, causing it to be continuously stimulated. This causes an initial increase of LH and FSH, then over the course of several weeks, causes the pituitary gland to become desensitised, pausing the natural sex hormone production for the duration the medication is taken. When the medication is stopped, its effect is reversed, with normal sex hormone production resuming about a week after the medication clears the body ( Cedrin-Durnerin et al., 2000 ).

GnRH agonists are prescribed as an injection administered every one to six months, a surgically implanted pellet once per year, or a nasal spray administered two to three times per day. A short-acting daily injection exists, but is not used for puberty blockade in clinical practise. Common examples of GnRH agonists include leuprorelin (Lupron; Eligard), triptorelin (Decapeptyl), goserelin (Zoladex), histrelin (Supprelin LA), nafarelin (Synarel) and buserelin (Suprefact).

Like GnRH agonists, GnRH antagonists bind to the GnRH receptor, however, they do not stimulate it. Instead, they compete with the body’s own GnRH, rendering it ineffective. As a result, they achieve similar effects without causing an initial increase in hormone levels. Also unlike GnRH agonists, oral formulations of GnRH antagonists exist, allowing some of them to be taken as a daily pill. Common examples include elagolix (Orilissa), degarelix (Firmagon), cetrorelix (Cetrotide), ganirelix (Orgalutran; Antagon) and relugolix (Orgovyx; Relumina). Unfortunately, being much newer drugs, GnRH antagonists are not normally used as puberty blockers at the moment.

In gender dysphoric youth, GnRH agonists are prescribed after the onset of puberty. GnRH agonists are not prescribed to children who have not yet started puberty, but may be started at any point during puberty to pause further changes ( Hembree et al., 2017 ).

Quality of Evidence

In medicine, the gold standard for evidence is the randomised controlled trial , or RCT. In a nutshell, participants are randomly assigned into two or more treatment groups (arms), such that the only difference between arms is the treatment they receive. Commonly, one group receives a placebo, while another receives the treatment being studied. The ideal RCT is blinded, meaning neither participants nor investigators of the study know which group is receiving which treatment. No such trials have been performed with puberty blockers, giving rise to concerns that there could be insufficient evidence available for their use.

Unfortunately, RCTs may not be practically possible for puberty blockers, and are unlikely to ever be performed. A good summary of the reasons for this is provided by Giordano & Holm (2020) :

There are two main practical problems that preclude conducting a RCT. First, patients who approach clinics for help because of distress caused by the first signs of puberty will be unlikely to accept to be a part of a RCT. Medications are needed within a relatively short period of time, at pain of treatment being less effective or ineffective. Recruitment would thus be hard if not impossible. Second, the ideal RCT is either double blind, i.e. neither researchers nor participants know who gets the active drug, or it assesses outcomes using blinded observers when treatment allocation cannot be hidden from participants. Blinding is necessary in order to reduce bias in outcome assessments. But, a RCT of puberty delay could not maintain blinding. Because GnRHa are effective in delaying puberty it would soon become evident to participants, researchers and outcome assessors who was in the active treatment arm and who was not. This breakdown of blinding would mean that there would be potential bias in the outcome assessments, both in relation to biological and psychological outcomes. It would also mean that participants allocated to the non-treatment arm of the study would be likely to either withdraw from the study at a much higher rate than in the treatment arm introducing potential bias, and/or be more likely not to adhere to the trial but seek puberty delaying treatment outside of the trial thereby adding a confounder.

Mul et al. (2001) ran into this problem conducting a similar study on teens with precocious puberty:

In the original study design a third arm with untreated children was scheduled as a control group. It was decided to omit this control group from the study design after it appeared that the parents of all patients who were randomized in the untreated control group refused further participation in the study as GnRHa treatment could be obtained elsewhere.

Besides practical limitations, such RCTs are likely to be unethical. Evidence suggests withholding puberty blockers may cause lasting harm in itself. To knowingly cause such harm to the control group of an RCT is likely to be morally unacceptable, and such an RCT would be unlikely to receive approval from an ethical review board.

This is not to say that studies evaluating such outcomes don’t exist at all: for example, while not randomised or blinded, Costa et al. (2015) compares 101 patients receiving psychological support and puberty blockers to 100 patients receiving psychological support alone. The results of this study are further outlined below.

As a result of these limitations, this article mainly cites cohort studies , making the argument that sufficient other high-quality studies exist to reach well-supported conclusions: a practise sometimes required in other areas of medicine as well. Because this is the only way we can practically evaluate puberty blockers and RCTs are likely impossible, it seems disingenuous to make the claim that lack of RCTs equate to lack of evidence around puberty blockers, as this standard of evidence can never be met, and the claim ignores a substantial existing body of literature.

Suicidality and Well-being

A significant body of evidence associates the use of puberty blockers in those who want such treatment with improved psychological well-being: the primary argument for their use.

While different studies use different methodologies, three standardised psychological questionnaires are typically used to evaluate well-being: the Children’s Global Assessment Scale (CGAS), the Child Behavior Checklist (CBCL), and the Youth Self-Report (YSR). All three are aimed at evaluating psychological functioning and problematic behaviour: typically, the CGAS is administered by a clinician, the CBCL is filled out by a parent or guardian, and the YSR is filled out by a child themselves. It’s important to note that scores in these assessments are known to markedly worsen in adolescence in general, with the onset of psychological difficulties and self-harm often appearing during puberty ( Verhuist et al., 2003 ; Nock et al., 2013 ; Morey et al., 2017 ; Jung et al., 2018 ).

One of the largest studies to investigate well-being to date has been Turban et al. (2020) . It surveyed 20,619 American transgender adults. 3,494 (16.9%) reported that they ever wanted to receive puberty blockers. Of those, only 89 received them. In total, 75.3% of those who received puberty blockers reported ever experiencing suicidal thoughts, compared to 90.2% of those who did not. After controlling for demographic variables like income, family support, and education level, puberty blockers remained significantly associated with decreased odds of lifetime suicidal ideation.

A similarly large survey by Green et al. (2021) included 11,914 Americans aged 13–24 who identified as transgender or nonbinary. The study compares those who received hormone therapy or puberty blockers to those who wished to receive them, but didn’t. It finds that in those who received treatment, rates of depression, suicidal ideation, and suicide attempts were significantly lower. This remained true of those aged 13–17, who were significantly more likely to receive puberty blockers specifically.

Costa et al. (2015) studied 201 gender dysphoric adolescents who presented at the British Tavistock and Portman NHS Gender Identity Development Service . Of them, half were considered eligible for puberty blockers immediately, receiving them in addition to psychological support. The other half were not considered immediately eligible for puberty blockers, citing reasons such as psychiatric problems or conflicts with parents and siblings. These patients received only psychological support for the following 18 months. All patients’ global psychological functioning was assessed using the CGAS questionnaire. Both groups showed significantly improved psychological functioning with psychological support, but the group receiving only psychological support stalled and showed no further improvement towards the end of the study, while those receiving puberty blockers continued to show greater improvement. The authors point out that the eventual CGAS score of the group receiving puberty blockers coincided almost perfectly with those found in a sample of children/adolescents without observed psychological/psychiatric symptoms.


CGAS scores of psychological functioning in transgender teens receiving puberty blockers and psychological support, compared to those receiving psychological support alone in .

A later study at the same British gender identity clinic, Carmichael et al. (2021) , received widespread media coverage in the United Kingdom following its mixed findings. It followed 44 gender dysphoric adolescents who received puberty blockers. CGAS scores were higher than the 2015 study at baseline, and showed slower and more modest improvement. The study reached contradictory conclusions, with improvements reported in some questionnaires, but not others, even for comparable measurements. Interestingly, in some of the researchers’ measures of well-being, social acceptance, and self-perception, adolescents themselves reported significant improvements, while their parents reported almost no improvement. The study characterises participants’ overall experiences with puberty blockers as positive, but is difficult to draw any conclusions from.

De Vries et al. (2011) and de Vries et al. (2014) investigate the psychological outcomes of the same cohort of transgender adolescents receiving puberty blockers at the VUmc gender clinic in the Netherlands. Both investigate psychological outcomes in a range of tests, with the 2014 study providing long-term follow-up many years after puberty blockers, and after gender reassignment surgery. In the studied cohort, psychological functioning improves and depression decreases over time, as evidenced by standardised tests, including CGAS scores. Significant improvements in well-being are reported both during treatment with puberty blockers, and in the years after, with hormone therapy and surgery. Unlike Carmichael et al., CBCL and YSR scores improve.

Van der Miesen et al. (2020) charts psychological well-being across 3 groups of Dutch adolescents: 272 transgender adolescents who haven’t yet received puberty blockers, 178 adolescents receiving puberty blockers, and 651 cisgender adolescents from the general population. The study finds poorer psychological functioning in those before treatment, while psychological functioning and well-being is similar to cisgender adolescents in those receiving pubertal suppression. These findings are in line with Costa et al. (2015) , which noted that those receiving puberty blockers reached CGAS scores comparable to the general (age-matched) population.


Percentages of teens who report suicidality in . Suicidality was defined as endorsing the statement “I deliberately try to hurt or kill myself” or “I think about killing myself.” Suicidality among Dutch transgender youth has not significantly changed over time, making cohort differences unlikely ( ).

In addition to the studies listed above, several smaller, less focused studies have also assessed the well-being of transgender adolescents receiving puberty blockers and reported overall positive experiences ( Khatchadourian et al., 2014 ; Achille et al., 2020 ; Kuper et al., 2020 ). No studies report a decline in psychological functioning or notably negative psychological outcomes with the use of puberty blockers.

In combination, this strongly suggests that puberty blockers improve well-being and psychological functioning in children who experience gender dysphoria. In addition, it suggests that inappropriately withholding them may lead to worse later-life outcomes, such as increased suicidality.

Counterintuitively, several of the studies listed do note that puberty blockers don’t reduce gender dysphoria ( de Vries et al., 2011 ; Carmichael et al., 2021 ). It’s important to be aware that this finding refers to the wish to transition, rather than psychological well-being. The finding is based on the Utrecht Gender Dysphoria Scale questionnaire ( de Vries et al., 2006 ). To illustrate, the version for transmasculine youth asks patients whether they endorse such statements as “I prefer to behave like a boy”, “I wish I had been born as a boy”, “I hate having breasts”, and “every time someone treats me like a girl, I feel hurt.”

When studies note that puberty blockers don’t reduce gender dysphoria, this means children don’t stop identifying as transgender after receiving puberty blockers. They continue to want to transition. De Vries et al. (2011) points out this is the expected outcome:

As expected, puberty suppression did not result in an amelioration of gender dysphoria. Previous studies have shown that only gender reassignment consisting of cross-sex hormone treatment and surgery may end the actual gender dysphoria. None of the gender dysphoric adolescents in this study renounced their wish for gender reassignment during puberty suppression. This finding supports earlier studies showing that young adolescents who had been carefully diagnosed show persisting gender dysphoria into late adolescence or young adulthood

Unlike hormone therapy, no risk of permanent infertility is believed to exist with the use of puberty blockers. Several long-term follow-up studies of patients treated with puberty blockers have found normal fertility. Among others, Feuillan et al. (1999) , Heger et al. (1999) , Heger et al. (2006) and Lazar et al. (2014) find no indication of impaired fertility in patients treated with puberty blockers for precocious puberty. In the years and decades following their treatments, the several hundred patients in these studies are found to conceive normally without an increased need for assisted reproductive technology, and with uneventful pregnancies. Despite several decades of use, no reports exist in literature of permanent infertility linked to puberty blockers. Interestingly, transgender populations do have higher rates of sperm abnormalities than cisgender populations, before any medical treatment has taken place ( Li et al., 2018 ; Rodriguez-Wallberg et al., 2021 ).

In contrast, hormone therapy may cause permanent infertility ( Hembree et al., 2017 ; Cheng et al., 2019 ). If fertility preservation has not been accessed before beginning treatment, puberty blockers must be stopped to do so, ideally before hormone therapy begins. When puberty blockers are stopped, unwanted sex characteristics continue to develop. Transgender people may find this extremely distressing, which may be one reason for them to not pursue fertility preservation.

No data exists on the exact length of time for which puberty blockers need to be stopped before full fertility is restored, and it likely varies depending on the age puberty blockers were initiated. Bertelloni et al. (2000) found spermarche took place between 0.7 to 3 years after discontinuation of puberty blockers in boys treated for precocious puberty. Barnard et al. (2019) report on the case of a single transgender patient who had been receiving puberty blockers for 6 months, from the age of 17. Three months after the last dose of monthly leuprorelin, no viable sperm sample could be produced. Five months after, their sample was viable.

Regardless of this, transgender individuals are extremely unlikely to use fertility preservation, with some estimates suggesting utilisation rates below 5% in North America ( Chen et al., 2017 ; Nahata et al., 2017 ). In one piece of research, Pang et al. (2020) questioned 102 transgender Australian teens on their reasons for declining fertility preservation. The following statistics were gathered:


Australian transgender teens’ reasons for declining fertility preservation in .

As such, there is no evidence-based reason to believe puberty blockers could cause infertility, with fertility returning when they are discontinued. However, due to low discontinuation rates for puberty blockers and low fertility preservation rates, those who start puberty blockers and persist are unlikely to have biological children. Clinical guidelines recommend that adolescents seeking puberty blockers should be counselled on options for fertility preservation, and parents should be involved in this ( Hembree et al., 2017 ).

Bone Density

Bone density is a measure of the amount of bone mineral present in bone tissue. Bone density is measured using imaging techniques, such as DEXA scans : a type of X-ray. It is used to predict patients’ risk of breaking bones. The clinical terms for low bone density are osteopenia , and in more severe cases, osteoporosis , which is common among the elderly. For the purposes of this review, the most relevant measurement of bone density is the z-score , which expresses a patient’s bone density in comparison to other people of the same age and sex. A z-score of 0 indicates bone density equal to the general population. Small deviations, such as -0.2, may not always be relevant, but z-scores below -1 may be cause for concern.

There are concerns around the effects of puberty blockers on bone health. Puberty is a critical time for the accrual of bone density: a process largely driven by sex hormones. This process is delayed in those receiving puberty blockers, leading to temporary lower bone density and z-scores compared to peers going through puberty normally. While these short-term z-scores are not particularly relevant, long-term outcomes are very important: the question becomes what z-scores look like in the long term, into adulthood, and whether the use of puberty blockers has any impact on later-life fracture risk. Literature on this is uncertain.

Klink et al. (2015) finds that in both trans girls and trans boys, z-scores are lower both before treatment, and after long-term follow-up. The study suggests a small negative effect on final bone density from the use of puberty blockers, although many measurements fail to reach statistical significance. The study records notably lower final z-scores for trans girls than trans boys.

Vlot et al. (2017) finds that 2 years after beginning hormone therapy, z-scores were returning towards normal. In trans boys, final z-scores were negligibly lower, while in trans girls, the effect was much more pronounced, with meaningfully lower z-scores both before and after treatment.

In line with this, Schagen et al. (2020) finds that in its cohort, final z-scores normalised after 3 years of hormone therapy for trans boys, while they remained meaningfully low both before and after treatment for trans girls.


Bone Mineral Apparent Density (BMAD) of the across multiple studies, relative to sex assigned at birth. Three measurements are taken in each study: the initiation of puberty blockers, the initiation of hormone therapy, and one measurement after several years of hormone therapy. A z-score below -1 is commonly considered to be clinically relevant osteopenia, while a score below -2.5 is considered to be osteoporosis. The figure illustrates that trans girls tend to have significantly lower bone density before, during, and after treatment, while this is not the case for trans boys. Trans girls also tend to receive puberty blockers for a longer time.

Bone Mineral Apparent Density (BMAD) of the across multiple studies, relative to sex assigned at birth. Three measurements are taken in each study: the initiation of puberty blockers, the initiation of hormone therapy, and one measurement after several years of hormone therapy. A z-score below -1 is commonly considered to be clinically relevant osteopenia, while a score below -2.5 is considered to be osteoporosis. The figure illustrates that trans girls tend to have significantly lower bone density before, during, and after treatment, while this is not the case for trans boys. Trans girls also tend to receive puberty blockers for a longer time.

Guaraldi et al. (2016) find in their literature review that in those receiving puberty blockers for precocious puberty, bone mineral density is lower than that of untreated peers during treatment with puberty blockers, then typically recovers when puberty is initiated, with long-term follow-up showing little difference to the general population. Combined with the results of trans boys, this suggests that not puberty blockers themselves, but rather, subsequent suboptimal hormone therapy in trans girls could potentially be to blame for their more pronounced negative outcomes.

The hormone therapy prescribed to trans girls in the listed studies may be suboptimal in several ways. To begin with, all three use very low adult maintenance dosages of no more than 2 mg oral estradiol in transfeminine patients. Such a dose is likely to produce serum estradiol levels of roughly 50 pg/ml on average: below the average estradiol exposure of cis women ( Aly, 2018 ; Aly, 2020 ). Many clinical guidelines recommend higher levels, which some research suggests could have a small positive effect on final bone density compared to lower dosages ( Roux, 1997 ; Riggs et al., 2012 ). Indeed, the authors of all three studies themselves note their doses were low and may have been inadequate for optimal bone density.

Also significantly, all studies use oral estrogens. Oral estrogens significantly reduce IGF-1 levels ( Isotton et al., 2012 ; Southmayd & De Souza, 2017 ), which is thought to play a vital role in bone density accrual, and strongly correlates with bone density ( Barake, Klibanski & Tritos, 2014 ; Locatelli & Bianchi, 2014 ; Ekbote et al., 2015 ; Lindsey & Mohan, 2016 ; Barake et al., 2018 ). Some experts have recommended transdermal estrogens over oral estrogens to improve bone density outcomes in girls suffering from Turner syndrome ( Davenport, 2010 ), and tentative evidence appears to support the practise ( Zaiem et al., 2017 ). As such, while not currently discussed in most clinical guidelines, the prevalence of oral estrogens in transgender teens is a concern, and avoiding them in favour of transdermal estrogens could lead to improved final bone density.

As a final confounding factor, none of the studies control for lifestyle factors associated with lower bone density, such as exercise, smoking, vitamin D, and calcium intake. These factors have a significant effect on bone density. Transgender people are more likely to smoke, less likely to exercise, and less likely to consume adequate calcium, both as teens and as adults ( Jones et al., 2018 ; Kidd, Dolezal & Bockting, 2018 ). This is believed to be the reason transgender people of all ages tend to have lower bone density before any treatment is initiated. Without controlling for these factors, which may distort the available data significantly, it’s difficult to draw confident conclusions from these studies, and a causal link between the use of puberty blockers and lower final bone density remains unproven. If such a link does exist, the effect seems unlikely to be dramatic, and unlikely to outweigh the benefits of puberty blockers.

In a noteworthy study, Antoniazzi et al. (2003) report that in those receiving puberty blockers for precocious puberty, bone mineral density is better preserved through calcium supplementation. Calcium intake is often inadequate in transgender youth ( Lee et al., 2020 ), and therefore warrants further study for improving their bone mineral density. Alongside calcium, lifestyle interventions, the use of transdermal instead of oral estrogens, and the avoidance of subphysiological adult dosages of estradiol could all potentially improve bone-related outcomes over current clinical practise.

IQ and Cognitive Development

One possible concern is the impact of puberty blockers on IQ and cognitive development. Very little research on the subject exists, with commonly cited critical studies investigating sheep rather than humans ( Hough et al., 2017 ), or being case studies of a single patient ( Schneider et al., 2017 ). Only two larger studies investigate this:

Staphorsius et al. (2015) , the only study to investigate this in a transgender population, evaluated performance in the standardised Tower of London test , as well as IQ scores. The study found no significant differences in executive functioning between the two groups. IQ was slightly lower in transgender girls receiving puberty suppression than the control group, but the same was not true in a statistically relevant way of transgender boys. Age differences, lifestyle factors, and a very low sample size may all explain these differences.

Wojniusz et al. (2016) assessed 15 girls suffering from precocious puberty and treated with a puberty blocker. The 15 girls were compared with 15 age-matched controls. Both groups showed similar IQ scores.

Neither study has very many participants, records baseline cognitive performance, or controls for confounding factors. As such, very few conclusions can be drawn from them. Decades of clinical experience with the use of puberty blockers in children suggests it’s unlikely any particularly dramatic effect on IQ exists, but without much larger, higher quality studies, no conclusion on this can be reached, and further research is needed.

Discontinuation rates for patients on puberty blockers are very low, with fewer than 5% of teens typically stopping them without going on to hormone therapy ( Wiepjes et al., 2018 ; Brik et al., 2020 ; Kuper et al., 2020 ). A potential concern is that this could mean puberty blockers put children on an almost guaranteed path towards gender transition, when they might otherwise change their minds.

Surprisingly, while a commonly held belief suggests most gender dysphoric children will grow out of it without treatment at a later age, little convincing evidence supports this claim. While existing studies report desistance rates ranging from 43% ( Wallien & Cohen-Kettenis, 2008 ) to 88% ( Drummond et al., 2008 ), they often contain significant methodological issues.

Historically, in the 20th century, a transgender identity was viewed as a negative outcome: it was something for a patient to be cured of, for example through aversion therapy. Since then, a cultural shift towards transgender people has taken place. Older studies into desistance rates are often reflective of this. As an example, Kosky (1987) describes eight boys who were hospitalised in a psychiatric unit for displaying effeminate behaviour and cross-dressing, where they received intensive treatment aimed at curing them. Today, these behaviours are more accepted, and they are not necessarily viewed as the same thing as a transgender gender identity. Clearly, a study like this cannot be used to estimate the desistance rates of today’s gender dysphoric children.

Other studies describing the 1960s through 1980s are similar ( Bakwin, 1968 ; Lebovitz, 1972 ; Zuger, 1978 ; Money & Russo, 1979 ; Davenport, 1986 ). Many predate the DSM-III , and thus the existence of formal diagnostic criteria. Few studied self-reported gender identity: instead, they tend to study gender non-conforming behaviour, such as cross-dressing, that doesn’t necessarily constitute a transgender identity. Many of them try to discourage patients as a core part of their treatment, sometimes in ways that are now banned across much of the world as conversion therapy . Combined with a drastically changed society, extrapolating modern transgender desistance rates from these studies is unreasonable.

A small number of more recent studies do exist. The highest desistance rates found in modern literature are approximately 88%, reported by three frequently cited Canadian studies: Drummond et al. (2008) , Drummond et al. (2018) , and Singh, Bradley & Zucker (2021) . Unfortunately, these studies appear to be at a high risk of bias: calling their credibility into question, the clinic in which they took place was closed in 2015, amidst allegations of conversion therapy. An independent review found that it “cannot state that the clinic does not practice reparative approaches.” In the review, many children and their parents report feeling the clinic was invasive and intimidating to them. Some instances include:

Assessments are described as intrusive and even traumatic by some, who described feeling “poked and prodded”. One way mirror and multiple observers create discomfort. Many questions were felt to be irrelevant, unnecessarily intrusive (particularly those regarding sexual fantasies), especially when asked without context, rationale, and what seems to be inadequate or even absent informed consent. Also, it is unclear whether any potential benefit of this line of questioning to the patient was explained. Parents of younger clients report their child appearing to be and later reporting feeling they were very uncomfortable with the way they were asked about their gender variance “as if my child was not okay as a person.” One parent described feeling “dismissed” when she spoke to clinicians about this.

Patients reported feeling intimidated to question Dr. Zucker regarding their concerns and were not offered the opportunity to decline. Multiple informants commented on this.

Chart documentation revealed statements reflecting that the diversity of gender expression and variance are not accepted equally. One example is of a child for whom all gender and body dysphoria had resolved and multiple informants indicated sustained good mood and satisfaction with social and academic functioning. Despite this, the parents of the child were advised at discharge to encourage the child to spend more time with cisgendered boys because he had effeminate speech and mannerisms. These were not goals of the client or family.

This may explain why these studies find a much higher desistance rate than other modern literature, and makes them very unlikely to be representative figures. As an alternative possibility, Steensma & Cohen-Kettenis (2018) suggest that differences in the local social climate regarding gender variance may have also been an important contributing factor.

Steensma et al. (2011) and Steensma et al. (2013) set out to investigate factors that could contribute to the persistence or desistance of gender dysphoria in children. The 2011 study reports a desistance rate of 45%, while the 2013 study reports 73%. The figures have been criticised because all children lost to follow-up are assumed to have desisted, which may or may not have inflated their number. More importantly however, in Steensma & Cohen-Kettenis (2018) , the authors themselves argue they’ve been cited out of context, and their figures can’t be used to extrapolate desistance rates:

Unlike what is suggested, we have not studied the gender identities of the children. Instead we have studied the persistence and desistence of children’s distress caused by the gender incongruence they experience to the point that they seek clinical assistance. […] Using the term desistence in this way does not imply anything about the identity of the desisters. The children could still be hesitating, searching, fluctuating, or exploring with regard to their gender experience and expression, and trying to figure out how they wanted to live. Apparently, they no longer desired some form of gender-affirming treatment at that point in their lives.

Again, because of the purpose and the design of this study we did not report prevalence numbers in the sample under study. Furthermore, the sample in the 2013 study did not include children in the younger age spectrum of the referred population to the Amsterdam clinic. Reporting prevalence of persistence and/or desistance in this sample would therefore not be reliable.

The only other modern study into persistence rates has been Wallien & Cohen-Kettenis (2008) . The study appears to be of higher quality and provides the most convincing estimate available: a 27% persistence rate and a 43% desistance rate over the course of (on average) 10 years. The remaining 30% of participants were lost to follow-up.

Several further problems cast doubt on the data presented in all of these studies, including Wallien & Cohen-Kettenis (2008) . Firstly: children are diagnosed using DSM-III and DSM-IV criteria, which are dated by today’s standards. In these older criteria, gender identity was not a diagnostic requirement: a child could be diagnosed with a gender identity disorder for a range of gender non-conforming behaviours, without themselves identifying as a different gender, or experiencing distress with their gender role or sex characteristics ( Temple Newhook et al., 2018 ).

Strikingly, with the exception of Steensma et al. (2011) , all studies include a significant number of children who never actually met then-current DSM diagnostic criteria for Gender Identity Disorder: in the case of Wallien & Cohen-Kettenis (2008) , a quarter of all participants. These participants have been assumed to be transgender for the purposes of extrapolating desistance rates, but held a diagnosis of Gender Identity Disorder Not Otherwise Specified: a broad category described by the DSM as representing those who may not necessarily seek medical transition, but may transiently cross-dress, be preoccupied with castration, or be intersex and experience gender dysphoria. These participants’ exact circumstances are not described by the researchers, but both Wallien & Cohen-Kettenis and Steensma et al. report in their studies that all, or nearly all persisters met DSM diagnostic criteria, while only about half of desisters did.

Outside of this, there is a lack of long-term follow-up. A gender dysphoric child might desist in transitioning during their teens, but go on to transition in adulthood, for example because of peer pressure or lack of parental acceptance. Whether this happens at any significant rate has not been studied.

The studies do suggest that for an unknown percentage of children, gender dysphoria will resolve over time, but the high desistance rates often cited as an established fact don’t appear to be supported by evidence. Concerns that puberty blockers cause children to transition when they otherwise would’ve aged out of gender dysphoria appear misplaced: children whose dysphoria persisted were much more likely to have met the diagnostic criteria to receive puberty blockers.

Current literature on this will likely soon be superseded by higher-quality data, with several very large, well-funded studies into gender dysphoric youth now underway the United States ( Olson-Kennedy et al., 2019 ), Australia ( Tollit et al., 2019 ) and the United Kingdom ( Kennedy et al., 2019 ).

Desistance and persistence rates can suggest a binary view, and should be seen in a greater context. Because children’s needs change over time, a hypothetical child might feel uncertain about their gender, possibly even receive puberty blockers, and then later decide they do not wish to transition. In such a case, puberty blockers may have met their needs at the time, and were not automatically harmful or regrettable, particularly due to their reversible nature. Neither being transgender, nor being cisgender should be seen as a negative outcome. In their critical commentary, Temple Newhook et al. (2018) write that it is important to respect children’s wishes and autonomy, and move away from the question of, “How should children’s gender identities develop over time?” toward a more useful question: “How should children best be supported as their gender identity develops?”

In light of persistence and desistance rates, it makes sense to ask how patients themselves feel about their treatment with puberty blockers, and whether they regret receiving them. Limited research exists on the subject:

A large retrospective review of the medical files of all 6,793 patients treated at the Dutch VUmc clinic between 1972 and 2015 found that 14 patients (0.2%) regretted their treatment in total. This included patients who received puberty suppression, hormone therapy, and/or surgery. Notably, 5 of them regretted their treatment because of a lack of social acceptance ( Wiepjes et al., 2018 ).

De Vries et al. (2014) , found none of the 55 transgender patients they followed regretted receiving puberty blockers, hormone therapy, or surgery. Psychological well-being continued to improve in their cohort, both with puberty blockers, hormone therapy, and later gender reassignment surgery.

Vrouenraets et al. (2016) interviewed 13 adolescents who had been seen at a Dutch gender identity clinic, twelve of whom had received puberty blockers. Asked about long-term risks, most responded that they were significantly outweighed by puberty blockers allowing them to live a more happy life. Quotes from the interviewed children in the study include:

The possible long-term consequences are incomparable with the unhappy feeling that you have and will keep having if you don’t receive treatment with puberty suppression. (trans boy; age: 18)

It isn’t a choice, even though a lot of people think that. Well, actually it is a choice: living a happy life or living an unhappy life. (trans girl; age: 14)

They also comment on the increasing attention to transgender people in media, with one child saying:

Thanks to media coverage I learned that gender dysphoria exists; that someone can have these feelings and that you can get treatment for it. Beforehand I thought I was the only one like this. (trans boy; age: 18)

Ease of Access

While large geographic differences exist, on the whole, access to puberty blockers is often difficult.

In the United States, Turban et al. (2020) found that access to puberty blockers was associated with a greater household income, noting that the annual cost of them ranges from $4,000 to $25,000 and insurance coverage was unavailable to many. It also found that transgender teens were less likely to receive puberty blockers if they did not identify as heterosexual or binary. Of those who received puberty blockers, 60% reported traveling <25 miles for gender-affirming care, 29% travelled between 25 and 100 miles, and 11% travelled >100 miles. As of 2021, several states are pursuing regulation banning the use of puberty blockers, with Arkansas having become the first to pass such a law. Several large professional bodies representing thousands of medical experts have condemned this type of regulation ( American Academy of Child and Adolescent Psychiatry, 2019 ; American Medical Association, 2021 ; Endocrine Society, 2021 ).

In the United Kingdom, waiting lists as long as 4 years or more exist for initial intake appointments for puberty blockers. Legislative changes in light of Bell v. Tavistock complicated access dramatically: in the nine months between the ruling and its reversal, no under-17s received puberty blockers under the public healthcare sytem, and reports described the care of adolescents over 16, who were not affected by the judgement, being discontinued as well. Restrictions in light of Bell v. Tavistock were condemned by WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, and PATHA, the leading medical associations for transgender health, who released a statement saying they believe it will cause significant harm to the affected patients ( WPATH, 2020 ), as well as Amnesty International UK and Liberty ( Amnesty International UK, 2020 ).

In Sweden, the Astrid Lindgren Children’s Hospital, a part of the Karolinska University Hospital , has recently stopped prescribing puberty blockers , citing the Bell v. Tavistock case as their motivation.

In Finland, new prescriber guidelines for treating gender dysphoric teens were released in 2020 ( Society for Evidence Based Medicine, 2021 ). They broke with WPATH guidelines, instead recommending that gender dysphoric teens receive psychosocial support and psychotherapy as a first-line treatment, and discouraging the use of puberty blockers, with the addition of much stricter criteria for their use. The Finnish health authority has stated that these recommendations will not be revised until further research is available.

A similar trend of increasing wait times and difficult access holds in many other countries, with the process to receive puberty blockers sometimes taking up to several years. Because of their time-sensitive nature in preventing unwanted permanent changes, long-term outcomes are likely to be worse with slower treatment. Some evidence supports this: for example, one study found that reducing treatment wait times led to reduced depression and anxiety compared to historical controls ( Dahlgren Allen et al., 2021 ).

Unknowns exist around puberty blockers in transgender youth, but their risks seem to be relatively minor based on available research, while clear evidence associates their use with improved well-being, psychological functioning, and reduced suicidality.

Based on parallels from research in cisgender teens treated for precocious puberty, as well as limited studies and clinical experience with transgender teens, it’s unlikely that puberty suppression has a dramatic negative effect on children’s final bone density, lifetime fracture risk, IQ, or cognitive development when prescribed in line with medical guidelines. However, there is insufficient evidence to determine whether or not they have any impact at all.

Although not supported by conclusive evidence, the use of puberty blockers may have a modest negative impact on bone density. This could be related to the use of puberty blockers themselves, but could also be related to suboptimal hormone therapy regimens after their use, particularly in transgender girls, as well as lifestyle factors. Studies investigating this suffer from significant methodological issues, and a definitive causal link remains unproven. Based on limited evidence, prescribers may wish to consider calcium supplementation in transgender teens receiving puberty blockers, and may wish to avoid oral estrogens in transgender girls beginning hormone therapy.

Compared to their cisgender peers, transgender adolescents who take puberty blockers are less likely to choose to have biological children, but puberty blockers do not permanently affect fertility.

Widely cited statistics around children growing out of gender dysphoria (“desistance”) as they grow older are based on highly unreliable data. Surprisingly, based on current evidence, we cannot reasonably guess the rate at which this happens. Regardless, desistance rates are not an argument for or against the use of puberty blockers. It is important to respect children’s wishes and autonomy, and to find the best way to support them as their gender identity develops, without imposing the idea that either a transgender or a cisgender gender identity is a bad outcome.

Very few patients who receive puberty blockers experience regret. In broader context, for the small minority of adult transgender patients who report feeling regret after undergoing hormone therapy or surgery, a common reason for that is a lack of social acceptance.

More high-quality research is urgently needed in this field. In particular, the effects of puberty blockers on IQ and cognitive development, bone outcomes, and desistance remain understudied subjects. Randomised controlled trials on puberty blockers are not available, and likely cannot be performed for both practical and ethical reasons. This should not be seen as a reason to discard all other research on the subject, or to label their use as experimental, as it is a standard of evidence that can never be met.

Puberty blockers are extremely difficult for patients to access in many countries, including the United States, the United Kingdom, and parts of Europe. Several countries have recently banned their use, or further restricted it significantly. This review provides further evidence supporting WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusAPTH, PATHA, the Endocrine Society, the American Academy of Child and Adolescent Psychiatry, and the American Medical Association in condemning recent attempts to bar transgender teens from receiving gender-affirming care, including puberty blockers. To better support gender dysphoric children, barriers of access should instead be reduced where possible.

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BOP Greenlights Sex Reassignment Surgery for Federal Prisoner in Texas

Wisconsin DOC Ordered to Provide the Surgery, Too

by Matt Clarke and Chuck Sharman

In a federal court filing on January 31, 2022, the U.S. Bureau of Prisons (BOP) indicated that a transgender prisoner in Texas could be cleared for gender conforming surgery (GCS) as early as March 2022. If that happens, the prisoner, Cristian Noel “Cristina” Iglesis, 47, will become the third prisoner in the U.S. ever to undergo the procedure—unless she is beaten by another prisoner also diagnosed with severe gender dysphoria in Wisconsin, whose Department of Corrections (DOC) was ordered to provide GCS by another federal court on December 8, 2020.

That DOC prisoner, Mark A. “Nichole Rose” Campbell, now 50, won a bench trial held in March 2020 in U.S. District Court for the Western District of Wisconsin to determine whether she had a serious medical need for the surgery and, if so, whether the defendant DOC officials were deliberately indifferent to that need by repeatedly denying her requests for the procedure.

According to the testimony of DOC’s gender dysphoria consultant, Cynthia Osborne, Campbell suffers from the most severe form of gender dysphoria, anatomic gender dysphoria, which means the presence of male genitalia causes severe mental anguish that puts her at substantial risk of self-mutilation or suicide.

Based on Osborne’s recommendations after a 2012 examination, Campbell began receiving mental health treatment and hormone therapy. Osborne conducted another examination in 2014, reporting that Campbell was a good candidate for GCS, but that optimizing hormone therapy should be attempted first. This was done, yet two years later, Campbell was still being denied surgery because it was against DOC policy.

The defendants contested whether the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People published by the World Professional Association of Transgender Health (WPATH) should be used to determine the medical necessity of GCS.

But the Court noted that Osborne uses the standards and DOC itself purports to follow them. It further found that those standards “represented the consensus of qualified medical professionals regarding the appropriateness of various treatments for gender dysphoria, including sex reassignment surgery.”

The central issue raised by DOC was whether it was possible for a person to live one year in the gender role of a female—a WPATH standard requirement—while incarcerated in a male prison. But prison officials also had concerns that prevented Campbell from being transferred to a female prison before the operation.

Swatting away that Catch-22, the Court noted Osborne’s testimony that the requirement of a year of “real-life experience was a common-sense practice based more on tradition than any science.” In a scholarly article she published, Osborne contended it was possible for a trans-woman to live in a woman’s gender role within a male prison. The Court then determined that neither issue precluded the surgery.

It also found that, for the severe unremitting anatomical gender dysphoria from which Campbell suffers, GCS is the only effective treatment. There was no question that, at least since Osborne’s 2014 report, defendants were aware of this. Nonetheless, they continued to deny Campbell’s requests because “DOC policy flatly prohibited sex reassignment surgery.” Therefore, the Court found that defendants were deliberately indifferent to Campbell’s serious medical needs in violation of her Eighth Amendment rights.

A previous appellate court decision in the case had already granted defendants qualified immunity, so damages were not at issue. The court said it would issue an injunction, ordering defendants to have Campbell assessed for and provided GCS, though not breast augmentation, voice therapy or electrolysis, since Campbell presented no expert testimony as to those procedures. Campbell was represented by Madison attorneys Iana Vladimirova, Joseph S. Dedrich, Natalia S. Kruse, and Thomas Patrick Heneghan of Hush Blackwell. See: Campbell v. Kallas , 2020 U.S. Dist. LEXIS 230117 (W.D. Wis.).

“Self-castration or Suicide Is Always There”

Iglesias, the BOP prisoner, had an even older diagnosis of gender dysphoria, dating back to 1994. After filing her suit pro se in U.S. District Court for the Southern District of Illinois, the state where she was then incarcerated, her complaint survived a preliminary screening in 2019. See: Iglesias v. True , 403 F. Supp. 3d 680 (S.D. Ill. 2019).

Iglesias was then appointed counsel, who filed an amended complaint that also survived the Court’s preliminary screening review. See: Iglesias v. Fed. Bureau of Prisons , 2020 U.S. Dist. LEXIS 201281 (S.D. Ill.).

Iglesias next filed for a preliminary injunction (PI) on April 19, 2021, seeking to force BOP to provide GCS and reassign her to a women’s prison, where she would be safe from the repeated attacks she had endured during two decades of intermittent incarceration in BOP facilities for men. Thirteen days later, on May 2, 2021, BOP transferred her to the Federal Medical Center at Carswell, Texas, which is a female facility.

Taking up the PI motion, the Court noted that BOP relied heavily on Campbell v. Kallas , 936 F.3d 536 (7th Cir. 2019), which held there was no deliberate indifference to a prisoner’s medical needs so long as some treatment was provided, such as hormone therapy in Iglesias’ case. Yet in that same ruling, the Court noted, the Seventh Circuit also held that “[d]enying a specific therapy in a particular case might amount to a constitutional violation.”

Moreover, the Court said, BOP had stonewalled Iglesias’ requests for surgery, hormone therapy and even reassignment to a women’s prison for years, during which time the prisoner made 12 suicide attempts. Iglesias herself testified that should GCS not happen, “self-castration or suicide is always there.” Testimony was also taken from an expert witness for Iglesias, Dr. Randi Ettner, immediate past president of WPATH, who said that Iglesias had met the organization’s criteria for recommending surgery by:

• having a well-documented diagnosis of gender dysphoria;

• being on hormones for years;

• living in her role for more than 12 months and being above the age of majority; and

• having any medical or mental health issues well controlled.

As a result, the Court said Iglesias’ complaint was likely to succeed on its merits, clearing the hurdle to obtain a PI. It ordered BOP to show cause by January 24, 2022, why it should not grant Iglesias’ request for surgery. See: Iglesias v. Fed. Bureau of Prisons , 2021 U.S. Dist. LEXIS 245517 (S.D. Ill.).

The deadline came and went, with no word from BOP, leading Iglesias and her attorneys— Josh Blecher-Cohen with the ACLU of Illinois, Angela M. Povolish of the Carbondale firm of Feirich Mager Green Ryan, Taylor Brown of the ACLU, as well as Katherine D. Hundt, Courtney Block, Frank Battaglia and Kevin Warner of the Chicago firm of Winston & Strawn LLP—to conclude that the agency was going to deny it.

That’s when BOP abruptly shared the recommendation of its Transgender Executive Council (TEC) that Iglesias receive GCS before her scheduled release at the end of 2022. U.S. Attorneys defending the agency said that “assuming [Iglesias] does not engage in behavior that would prevent her from continued placement in a female facility and assuming further that no other reasons develop that would make gender confirmation surgery inappropriate, the TEC does expect plaintiff to be referred to a surgeon at the appropriate time.”

Unsurprisingly, perhaps, the use of public funds to provide sex reassignment surgery has provided red meat to some conservative news sites, especially in the case of Campbell, who is serving a 34-year sentence earned in 2007 for a conviction on a First Degree Sexual Assault charge involving her 10-year-old daughter. It could reportedly take up to a year for her to be assessed for surgery because Wisconsin has only one surgeon performing the procedure.

Two other prisoners have already received GCS: Shiloh Heavenly Quine in California in 2017 and Adree Edmo in Idaho in July 2020.

Additional sources: Christian Post, The Hill, Idaho State Journal, Los Angeles Times, Cannon Falls Republican Eagle

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Related legal cases

Iglesias v. fed. bureau of prisons.

Year	2021
Cite	2021 U.S. Dist. LEXIS 245517 (S.D. Ill.)
Level	District Court
Conclusion	Bench Verdict

Campbell v. Kallas

Year	2020
Cite	2020 U.S. Dist. LEXIS 230117 (W.D. Wis.)
Level	District Court
Conclusion	Bench Verdict

Year	2020
Cite	2020 U.S. Dist. LEXIS 201281 (S.D. Ill.).
Level	District Court
Conclusion	Bench Verdict

Iglesias v. True

Year	2019
Cite	403 F. Supp. 3d 680 (S.D. Ill. 2019)
Level	District Court
Conclusion	Bench Verdict
District Court Edition	F.Supp.3d

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What It's Like To Choose Transgender Sex Reassignment Surgery

Meredith Rizzo

It wasn't until Deborah Svoboda dated someone who is trans that she understood how little she understood about being transgender. "I realized how very misunderstood they were, including by me," she says. And that comes from someone who identifies as queer and has lived and worked in diverse communities.

So Svoboda decided to use her skills as a multimedia journalist to learn about one aspect of transition: sex reassignment surgery. Surgery is something that people tend to fixate on. The "Did she or didn't she?" aspect of it even came up in Vanity Fair's coverage of Caitlyn Jenner's transition .

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'call me caitlyn': bruce jenner reveals new name.

Svoboda put flyers up in LGBT health clinics in the San Francisco area, asking people if they would be willing to let her document the experience. Jamie Nelson, who says he identifies as a transgender male who is queer, and Jetta'Mae Carlisle, who says she identifies as a straight woman, said yes. Both were preparing to have surgery, and were willing to let Svoboda follow them through the process.

"They also both wanted to tell their stories for the purpose of breaking down fears and misunderstandings around trans people," says Svoboda, who lives in Emeryville, Calif. "I could see that these two people both had an incredible amount of courage and openness that I knew we needed to tell such an intimate and in-depth story."

Jenner: 'For All Intents And Purposes, I Am A Woman'

She met with Nelson and Carlisle for almost a year. As the surgery dates grew closer, she met with them daily to photograph, video or gather audio. Carlisle flew to Phoenix for her surgery, "So I drove there and spent a week documenting her experience, physical and emotional."

In the end, Svoboda says, she learned an incredible amount. "The lengths they have had to go through in order to be themselves inspire me," she says. "They've been forced to ask for what they need, to face criticism, rejection and even degradation. They've gone through pain and confusion and still they find a way to hold their heads up and say, 'This is who I am.' "

The video originally appeared on KQED's State of Health blog.

transgender

Ban against youth gender-affirming procedures faces lawsuit

The lawsuit was filed on wednesday by families and medical providers against senate bill 14 before it goes into effect on sept. 1, by nbcdfw staff , acacia coronado and jim vertuno • published july 13, 2023 • updated on july 14, 2023 at 12:15 pm.

A lawsuit brought about by Texas families and medical providers aims to block a bill that bans gender-affirming procedures for minors, arguing it violates parental rights and discriminates against transgender teens.

The lawsuit was filed on Wednesday in Travis County, legal representatives announced. It seeks a temporary injunction to block Senate Bill 14 which was signed by Gov. Greg Abbott in June and is set to go into effect on Sept. 1. The Associated Press said they reached out to Abbott's office but he has not responded.

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SB14 bans transition-related care for transgender minors. This includes treatment for gender transitioning and gender reassignment. Various surgeries and medical prescriptions, such as hormone therapies and puberty blockers, are also detailed in the bill.

Texas children who already started such care are required to be weaned off in a "medically appropriate" manner.

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Behind the lawsuit are five Texas families, three medical professionals, and two organizations that represent various people across the state.

The families have transgender children between the ages of 9 and 16, who cite irreparable harm if the bill goes into effect. Concerns stem from mental health to bodily autonomy.

"As a parent, I don't want to see my child suffer and don't understand why the state government would try to strip away my ability to seek the best possible health care for my child," said Lazaro Loe, father of a transgender girl, in a statement. "If SB14 goes into effect and Luna loses access to this health care, I am deeply concerned about the anxiety, depression, and suicidality that she will face. Her happiness, health, autonomy, and independence would be stripped away by this cruel legislation; and we likely would be forced to leave our home here in Texas."

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The lawsuit argues that the ban will have devastating consequences for transgender teens in Texas, who they say will be unable to obtain critical medical treatment recommended by their physicians and parents.

According to the lawsuit, many transgender teens will "face the whiplash of losing their necessary medical treatment and experiencing unwanted and unbearable changes to their body."

"I am gravely concerned about my patient's ability to survive, much less thrive if SB 14 takes effect," Richard Ogden Roberts, a doctor who is a plaintiff in the lawsuit, said on behalf of himself and his patients.

Roberts, who has cared for over 200 gender-diverse and transgender young patients and their families, said in the lawsuit he and his colleagues worry they will be forced to choose between upholding their medical oaths or upholding the state's new law.

As more states have moved to enforce bans, families of transgender youth are increasingly forced to travel out of state for the care they need.

Every major medical organization, including the American Medical Association, has opposed the bans and supported medical care for youth when administered appropriately. Opponents of gender-affirming care say there's no solid proof of purported benefits, cite widely discredited research and say children shouldn't make life-altering decisions they might later regret.

Similar lawsuits have surfaced across various states in the U.S., which also have bills that seek to ban gender-affirming care.

There are 20 states that have adopted laws banning youth gender-affirming care, according to the Human Rights Campaign. The Associated Press reports half of those laws are not in effect, either because they were passed so recently that they haven't yet kicked in or, in the case of Arkansas, Indiana and Kentucky, because enforcement has been put on hold by courts.

A judge in June also blocked enforcement of Tennessee's ban, but an appeals court this month said it can take effect for now, at least.

Last year, Abbott became the first governor to order the investigation of families who were receiving care. The investigations were later halted by a Texas judge.

When legislators returned to Austin in January for the state's biennial legislative session, they created SB 14, which codified a ban on transgender care for minors into law.

The transgender care ban was one of the most divisive issues of this year's Texas legislative session. Transgender rights activists disrupted the Texas House with protests from the chamber gallery, which led to state police forcing demonstrators to move outside the building.

Children's hospitals around the country have faced harassment and threats of violence for providing such care. Suspended Republican Texas Attorney General Ken Paxton, who faces a Senate impeachment trial in September on allegations of corruption and misuse of office, had previously opened investigations into transgender care at an Austin hospital.

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Review Article
Published: 12 April 2011

Gender reassignment surgery: an overview

Gennaro Selvaggi 1 &
James Bellringer 1

Nature Reviews Urology volume 8 , pages 274–282 ( 2011 ) Cite this article

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Pathogenesis
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Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

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Principles and outcomes of gender-affirming vaginoplasty

Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review

The effect of early puberty suppression on treatment options and outcomes in transgender patients

Change history, 26 april 2011.

In the version of this article initially published online, the statement regarding the frequency of male-to-female transsexuals was incorrect. The error has been corrected for the print, HTML and PDF versions of the article.

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G. Selvaggi and J. Bellringer contributed equally to the research, discussions, writing, reviewing, and editing of this article.

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Court orders first gender-affirming surgery for a transgender federal prisoner

In a first, the Federal Bureau of Prisons has been ordered to secure gender-affirming surgery for a transgender prisoner.

A federal judge in the U.S. District Court for the Southern District of Illinois ordered the bureau on Monday to undergo a nationwide search for a qualified surgeon to perform the surgery for the inmate, Cristina Nichole Iglesias.

The directive will bring Iglesias — who has been imprisoned since 1994 for threatening to use a weapon of mass destruction — a step closer to receiving the procedure, which she has been fighting to get for six years, the last three in the courts.

“I am hopeful that I will finally get the care I need to live my life fully as the woman I am,” Iglesias said in a statement provided to NBC News by her legal representative, the American Civil Liberties Union. “BOP has denied me gender-affirming surgery for years — and keeps raising new excuses and putting new obstacles in my way. I am grateful that the court recognized the urgency of my case and ordered BOP to act.”

Monday's court order could pave the way for other transgender prisoners to receive gender-affirming surgeries as well. LGBTQ advocates have called these procedures "life-saving," and Monday's decision could bolster the Biden administration's goal of improving the lives of incarcerated transgender people.

A 2015 report by the Justice Department estimated that 35 percent of trans prisoners surveyed had reported being sexually assaulted behind bars within the last year. Under the Trump administration, the Bureau of Prisons was required to “use biological sex as the initial determination” for housing trans prisoners.

A 2020 NBC News investigation that tracked 45 states and Washington, D.C., found that out of 4,890 transgender inmates in state prisons, only 15 were confirmed to being housed according to their lived gender.

In January, the Biden administration restored Obama-era guidelines for federal prisons to house transgender inmates by their gender identity "when appropriate." The guidelines also require prison staff to refer to trans inmates by their lived name and pronouns.

The ACLU estimates that the Federal Bureau of Prisons has more than 1,200 transgender people currently in its custody.

Iglesias has been in federal prison for roughly 28 years and currently lives in a bureau-run residential re-entry center in Florida, according to the ACLU.

Although she identified herself as a woman upon her incarceration, she has been housed in men's facilities for over two decades, and during that time has experienced physical and sexual violence, the ACLU said. In May, her lawsuit to seek gender-affirming surgery resulted in her being one of the few transgender federal prisoners moved to a facility that corresponds with her gender identity.

Iglesias then became the first transgender prisoner to be evaluated for gender-affirming surgery, which the Bureau of Prisons recommended in January. However, the ACLU said in a statement that the bureau had "sought to postpone any referral to a surgeon for months."

In Monday's ruling , Judge Nancy Rosenstengel slammed the prison bureau's handling of Iglesias' case and compared its "tactics" to a game of “whack-a-mole.” Rosenstengel also ordered the bureau to provide the court with weekly updates and a detailed plan to ensure that Iglesias gets the surgery before her release in December.

The Bureau of Prisons told NBC News in a statement that it does not comment on “pending litigation or matters subject to legal proceedings,” nor on “the conditions of confinement for any individual or group of inmates.”

“For years, Cristina has fought to receive the health care the Constitution requires," Joshua Blecher-Cohen, an ACLU of Illinois staff attorney who represents Ms. Iglesias, said in a statement.

"The court’s order makes clear that she needs gender-affirming surgery now and that BOP cannot justify its failure to provide this medically necessary care," he said. "We hope this landmark decision will help secure long-overdue health care for Cristina — and for the many other transgender people in federal custody who have been denied gender-affirming care.”

Follow NBC Out on Twitter , Facebook & Instagram

Matt Lavietes is a reporter for NBC Out.

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