It’s Time for Liberal Physicians to Rethink American Gender Medicine

The Ethics of the Gender Affirming Hysterectomy

I performed my first hysterectomy for gender confirmation in 2019. I was so delighted to help out my own LGBT community. I took immense pride in being my local LGBT clinic’s official gynecologist. What greater joy is there in medicine than providing great care to a vulnerable, underserved community, all with the support of your administration? It was how the world should be.

Six years later, I wonder.

The hysterectomies went well. They were uncomplicated. Even the one patient who came back to see me for well woman care after detransitioning didn’t tell me she regretted her surgery. I hope that all those patients are still happy not to have their uteri. But in terms of the clinic overall, staffed by earnest, well-meaning clinicians as it was – were we doing the right thing?

In some cases, I don’t think we were.

The background

In 2019, I took a job as an Ob/Gyn at a nonprofit health system in northeast Iowa after my private practice went out of business. I had a wife, twins in preschool, and a toddler.

I loved the progressive policies of my new employer, especially after having privileges only at a Catholic hospital. My new employer even sponsored an LGBT clinic. This was an after-hours clinic that provided a comfortable space for LGBT patients who may not feel comfortable in a mainstream doctor’s office to get primary care, and they also provided medical transition services to transgender patients. I was thrilled to sign up to be their gynecologist and come to the clinic once per month to provide my expertise to anyone who needed it.

 I was somewhat surprised that the clinic seemed almost exclusively T, without much LGB.  I’d had my head down from 2011-2019; training, getting married, having kids and starting my practice. I found the LGBT world was very different in 2019 than it had been the last time I had really been around other gay people.

But I was on board and ready to support my community. Sure, there were uncomfortable questions – hadn’t we learned in medical school that most pediatric gender dysphoria resolves by adulthood? If so, did it make sense for young adolescents to transition to the opposite sex? Was it really plausible that transgender female athletes didn’t have a biological advantage over cis girls and women? The accepted answers seemed counterintuitive – however, I assumed that the experts had carefully weighed the evidence, had done plenty of research, and had reached a scientifically-based consensus before making their recommendations regarding gender medicine.

For a few years, I essentially became the go-to gynecologist in my community for gender-affirming hysterectomy referrals. I enjoyed taking care of my transmasculine patients. Some of them drove hundreds of miles from their homes in rural Iowa to receive their care in our LGBT clinic. I felt good about providing such a much-needed service. As I would joke to my assistant, a gender affirming hysterectomy referral was “my easiest consult of the day.” They came in knowing what they wanted: a hysterectomy. Unless they had a major contraindication to surgery, like uncontrolled diabetes, it was an easy decision to book it. Unlike hysterectomies for abnormal bleeding or pelvic pain, there was no need to document prior attempts at treatment, failures, and impact on the patient’s life for the insurance companies to authorize these hysterectomies. “Gender dysphoria” always got approved (with the requisite two letters, one from a mental health professional and one from a PCP).

Of course, I counseled my patients. Would they like their ovaries conserved or removed? I was adept at discussing the risks and benefits of both approaches. I offered referral for egg freezing if they desired oophorectomy. I discussed surgical risks and expected recovery.

Gender affirming hysterectomies were a delight to perform. “These teeny tiny uteri [atrophied by testosterone] are so much fun to take out,” I would tell my assistant. Unlike hysterectomies for more traditional diagnoses such as abnormal uterine bleeding or pelvic pain, these uteri rarely came with pathology such as fibroids, adenomyosis, or endometriosis to make surgery more difficult.

Having some doubts

As the years went by, I couldn’t help but notice some troubling trends. The transmasculine patients who came to me had more and more poorly controlled mental health comorbidities. I also started seeing a fair percentage of them who were really quite feminine – not much different in their gender presentation than my cis patients.

I started to be a little more uneasy that hysterectomy was the right thing for this new group of transmasculine patients, but if they didn’t have any contraindications per se, I couldn’t really say no. After all, according to ACOG Committee Opinion #823, Health Care for Transgender and Gender Diverse Individuals, “Hysterectomy with or without bilateral salpingo-oophorectomy is medically necessary for patients with gender dysphoria who desire this procedure.”

The end of an era

Finally, I had the patients that truly stymied me: 21-year-old natal females who identified with a nonbinary gender identity and requested hysterectomy to conform to their nonbinary gender identity, but otherwise did not desire transmasculine medicalization such as testosterone or mastectomy, and had unremarkably feminine mannerisms and dress.

Let’s, for a moment, talk about the path to hysterectomy a cis female with abnormal bleeding or painful periods must walk. A hysterectomy is a major surgery that conveys numerous surgical risks, including death, as well as irrevocable lifelong infertility. (Even after tubal ligation, a woman can typically become pregnant with IVF, but there is well and truly no baby making after a hysterectomy.)

As a medical system, for better or worse, we make our traditional gynecologic patients with miserable periods jump through quite a few hoops before they are approved for hysterectomy. Generally, they have to have a full workup for any reversible medical reason for their miserable periods and try some sort of medical management of their heavy periods, because it is such a grave decision to take a patient for a major surgery like hysterectomy with all the accompanying risk (death, bowel injury requiring lifelong colostomy, urologic injury requiring lifelong urostomy, chronic debilitating surgical pain, vaginal cuff dehiscence with evisceration, massive blood loss, stroke, etc.)

By contrast, according to medical guidelines currently in play, a uterus-having person need only walk into a gynecologist’s office, declare themselves to have a nonbinary or male gender identity, and endorse dysphoria from the presence of their uterus to qualify for hysterectomy.

Now, there is a reasonable argument to be made that any woman should be able to have a hysterectomy on demand. But that is not the world we live in at present.

I thought the WPATH guidelines might help my dilemma. Maybe WPATH (the World Professional Association for Transgender Health) had something helpful to say about hysterectomy considerations for nonbinary individuals – some sort of criteria I could look to.

 As I puzzled over the “Nonbinary” WPATH SOC 8 guidelines (Standards of Care, 8th edition, 2022), I found no clarity. “Motivations for accessing (or not accessing) gender-affirming medical interventions, including hormone treatment, surgeries, or both are heterogeneous and potentially complex and should be explored collaboratively before making decisions about physical interventions,” I read. Although that seemed like solid advice, I did not feel particularly well equipped to do so as a surgeon, rather than a mental health professional.

Still wondering how best to take care of my patients, I went to a private forum for Ob/Gyns to ask about how others addressed nonbinary individuals who requested gender affirming hysterectomy. I was told my question was “transphobic.” I was told that gender affirming hysterectomy in nonbinary people was “life saving” (presumably due to the suicidality brought on by the presence of one’s natal uterus). Academic gynecologists from leading institutions agreed that regardless of one’s gender identity, if it did not include a uterus, then hysterectomy was indicated. Quite straightforward.

It didn’t sit well with me. I wondered about my patient who had detransitioned just a few years after her hysterectomy. Conventional wisdom said detransition almost never happened, that the rate was just 1%. Well, I certainly hadn’t done a hundred hysterectomies for gender affirmation. So what was going on here?

And is it really unreasonable and bigoted to note a patient’s traditional feminine attire and presentation, when the indication for the surgery she is requesting is discomfort with her female gender?

I was curious about whether detransition was more common than we thought. I found my way to Hannah Barnes’s excellent book, Time to Think, which detailed the scandal at Great Britain’s national youth gender medicine clinic. Barnes found that distressed adolescent girls with no longstanding history of gender dysphoria were requesting to become boys at skyrocketing rates and being prescribed puberty blockers and testosterone with very little medical or psychiatric evaluation, while the adults in the room were deemed “transphobic” for raising any concerns about what was happening.

I kept reading. I found Jesse Singal’s work regarding the scientific basis of youth gender medicine. I learned about the relatively poor evidence base that youth gender medicine is built on. Certainly, there have been some studies that seem to show favorable short-term mental health outcomes for youth who access gender medicine. There have also been scandals about burying the outcomes of major studies at Johns Hopkins and Children’s Hospital of Los Angeles.  It seems nobody has published a long-term, longitudinal study on how these young people are doing. In fact, Great Britain’s public gender clinic, it seems, has refused to allow researchers access to their data. It seems that nobody knows what the true incidence of detransition is for young people who started a medical transition, but according to the most credible expert in the field, Dr. Kinnon MacKinnon, who is himself an openly transgender man, “it is very unlikely to be only 1%.”

I was surprised that there are no specific requirements for the psychological evaluation of young adolescents before starting them on the medical gender transition pathway. WPATH guidelines make recommendations that the young person have demonstrated “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration,” but in practice, even this minimum requirement has not consistently been followed. Although the WPATH SOC 8 advise that a basic mental health evaluation of transgender-identified adolescents be performed before starting medical gender transition[i], even this minimum and bland standard is controversial. Dr. Johanna Olson-Kennedy, President-Elect of USPATH, has been an outspoken advocate of the “informed consent” model, deeming the requirement of any psychological evaluation prior to starting a medical transition to be excessive gatekeeping.

I was surprised to find out that, while many youth gender clinics have a long and thoughtful process for evaluating patients to determine who would benefit from medical transition, there are others that routinely provide prescriptions for puberty blockers or hormones at patients’ first appointments, even when a patient does not have a longstanding history of gender dysphoria since early childhood.

I found an emerging population of detransitioners, individuals who have took steps to medically transition and who have now reverted to their natal gender identity. Although some do not regret the changes they made to their bodies, some are profoundly distressed by them. Some feel they cannot access adequate medical guidance for detransitioning. Some have serious and credible critiques of the gender medicine system as it stands.

I had just assumed somebody, somewhere was in charge of making sure that there was an evidence base that these extraordinary treatments that were being performed on young people – puberty blockers, cross-sex hormones, and double mastectomy – were support by extraordinary scientific evidence that showed an incontrovertible long-term benefit.

However, since there was no unbiased scientific organization of experts on transgender issues, the AAP, the Pediatric Endocrine Society, the APA, the AMA, and ACOG relied on WPATH to guide them. Why wouldn’t they? As upstanding evidence-based scientific organizations, they generously assumed their counterparts were the same. However, as the holes in the evidence behind WPATH’s official Standards of Care become more obvious, it is clear these organizations can rely only on themselves to evaluate the evidence. (Interestingly enough, the American Society of Plastic Surgeons conducted its own review of the evidence, and, contrary to the interests of its own members, concluded that gender affirming mastectomy for minors is not ready for prime time.) 

Gender Dysphoria

Let’s return to our own little gynecology corner of the world of transgender medicine. What does it mean to have a hysterectomy for gender confirmation?

One of the things that I noted in LGBT clinic was that the moment a transgender-identified person stated a biological process gave them “gender dysphoria,” the system jumped into place to reverse the biological process, no matter how risky, painful, or expensive it may be.

The profound psychologic pain of gender dysphoria is real. And many adults have found happiness after medical transition. But what isn’t clear is whether medical transition for adolescents still developing their identities is the solution that many hope it is. A 2024 study from Finland – a progressive nation, with a strong social safety net and a tradition of women’s rights – found that medical transition in gender dysphoric adolescents did not decrease the risk of suicide.

After all, is it really credible that gender dysphoric adolescents, who we know have existed across societies for millennia, became distraught to the point of widespread suicide regardless of how accepting their societies were, because they could not access puberty blockers, cross-sex hormones, and mastectomies, all of which were not available anywhere in the world until the first youth gender medicine clinic opened in the Netherlands in the 1990s? This is a serious claim. If it were true, of course, medical and surgical transition should be available to any gender dysphoric adolescent who desires it. It would be reasonable to minimize potential harms of early medical transition, because of its life-saving nature. However, although this is a widely accepted trope, the evidence is truly scanty that the medical transition process itself, above and beyond the compassion and acceptance that patients find in a youth gender clinic, prevents suicide.

It is an extraordinary claim that, based on an adult patient’s stated gender self-identity, they should have hysterectomy, mastectomy, penectomy, oophorectomy, vaginoplasty, rhinoplasty, cheek implants, brow reduction, chin and jaw reshaping, liposuction, breast augmentation, vocal cord shaving, and various surgeries to create nonbinary genitalia deemed medically necessary without any more specific evaluation than a supporting letter from a therapist.

I have not seen extraordinary evidence.

Getting it wrong

It’s OK to be wrong sometimes.

In medicine, sometimes we get ahead of ourselves. New treatments that seem so promising at first end up not panning out. The widespread prescription of oxycodone as a panacea for chronic pain in the 2000s is a good example of this. The doctors who prescribed it wanted to help their patients. We just didn’t realize oxycodone’s harms until they became common enough to see.

I’d like to believe that we are people of science; that we realize when it is time to course correct.

On gender medicine, the time to course correct is now.

It is time for experts in our professional organizations who do not have a vested interest in perpetuating the current treatment paradigm in youth gender medicine to step up – to make truly evidence-based recommendations for standards of care.

It is time to seriously ask ourselves what the safest, least harmful interventions are in youth gender medicine, and hold these interventions to rigorous, data-driven standards. It may be reasonable at this juncture to halt new starts of medical and surgical treatments for minors (puberty blockers, cross-sex hormones, and mastectomies and other surgeries) outside of well designed, longitudinal clinical trials.

It is time to provide resources within the institutions of mainstream medicine for people who seek detransition care.

It is time to question whether “gender dysphoria” as an indication in and of itself for hysterectomy, without abnormal bleeding, pain, or any other diagnosis, should continue to bypass all of the checks and balances inherent in our healthcare system for major surgery.

My fellow gynecologists, we are people of science. We know right from wrong. We care about our patients. We can find the courage to do this.

Dr. Karla Solheim, MD, FACOG

[i] 6.12- We recommend health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when: 6.12.a- The adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICD, other taxonomies may be used although efforts should be undertaken to utilize the latest ICD as soon as practicable. 6.12.b- The experience of gender diversity/incongruence is marked and sustained over time. 6.12.c- The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment. 6.12.d- The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.