Talk:Sex reassignment therapy/Archive 1

More about surgery

 * I would like to know more about how the surgery is performed. I think that's why a lot of people are looking at the page.  Saritamackita 18:59, 1 February 2007 (UTC)

Dr John Money

 * Perhaps this page should reflect something about that Dr John Money that was in the news several years ago. As far as I can remember, there were two identical twins and one had surgery and was raised as a girl, only to be changed back later. The doctor engaged in some rather questionable practices also... I could not write an article about this, but if anyone is willing, there is already an article on him to get anyone started. Seems like it could use a bit more information though. And it seems that these two articles should be linked in some way, as the subject matter definitely overlaps... see also perhaps? (unsigned)
 * John Money was an avid transsexual activist, and believed strongly in the psychological theories of transsexualism and gender identity. the case you are talking about is David Riemer or the "John/Joan" case. Although john Money worked with transsexuals, the John/Joan case is more about Intersex issues (Although Iatrogenic, it was a case of genital ambiguity rather than a gender identity disorder that led to David's treatment)
 * Many of Dr. Money's theories are no longer widely held, however I do point out that he did a lot of very important early research and activism on behalf of transsexuals.
 * Including this in this article would make sense in a historical context.
 * Cheers!  Lauren  ♫/∆ 01:04, 27 March 2007 (UTC)

mtf anf ftm
First, thanks, Dysprosia, for cleaning up after me. I put back mtf and ftm before the respective procedures, though, because it makes a lot of sense to keep it that way. After all, mtfs don't have mastectomy, and ftms do not require or desire breast augmentation. However, these surgeries are often understood to be SRS too. Or probably even better, I'll put them under appropriate headers. -- AlexR 09:23, 1 May 2004 (UTC)

Post-op transsexuals
Is it true that "few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them"? IIRC, about 30 % were not happy with the decision or the outcome, and that was why it is debatable if that form of treatment is at all suitable. (I'll look up the source when I have time.) 82.154.18.15 02:08, 28 Dec 2004 (UTC)


 * See Transsexual. Dysprosia 03:13, 28 Dec 2004 (UTC)
 * And do have a look at that . It should answer that question very thoroughly. This might be the study which gives those 30%, but note that it is the only one with such a rate, and in most "unsuccessful" cases, it is the author of the study who thinks that a transition was unsucessful, not the people themselfes reporting that. If you have yet another source with a similar result, please let us know.
 * Today, the rate of people who feel that they were fundamentally wrong in their decision to transition (regardless of medical procedure) is usually given as "about 1% or less". Of course, the rate of those who are not satisfied with the outcome of a particular medical treatment is far larger, but that is the case for almost every medical treatment. For example, the result of my mastectomy is unsatisfactory, but I neither regret transitioning, nor the decision to have it. I do very much regret though that the doctor, who usually produces very good results, obviously had a bad day when he operated on me, but the very same problem might have appeared with any surgery.
 * There is BTW not much of a debate at all whether gender reassignment treatment is suitable - it is the only treatment that does work at all, and with a very good overall success rate, too. The only people who debate that are those who insist that such treatments or in fact transitioning is somehow "moraly wrong" and/or that there are other treatments that work. The later has however been sufficiently disprooven.Its against the law of nature to change the gender.
 * And one last thing: Do get yourself a username, IP numbers are always viewed with lots of suspicion - plain experience, nothing personal. -- AlexR 04:29, 28 Dec 2004 (UTC)
 * It is very hard to define "Failure" in terms of SRS/GRS/SRT. The most commonly used measure is "Detransitions" or "Reversion to former gender role" after surgery. Several cruicial factors have been found in several studies, mostly 1)lack of adequate Real life test, 2)Psychiatric Co-morbidity, and 3)A moral or religous conviction that such treatment is wrong. Other factors may include "autogynephilia" (usually meaning lesbian transsexuals such as myself, but actually meaning people who have a fetish for the idea of themselves as female, not nessecarily to live in a female gender) and poor access to surgery techniques
 * Many stories told of people who were "forced into sex change operations" actually admit to lying to clinicians. Although this is regarded as common due to the strong desire for treatment and fear of refusal of treatment
 * Studies in 1992, 1998, 2001 and 2006 consistently show a less than one percent rate of de-transition. As one psychiatrist pointed out, That's awfully good considering the cure rates of most "psychiatric illnesses" (I.E. 100% failure over time for anything bar depression and anxiety).
 * Even a cochrane review article suggests that SRS is a viable economic treatment, reducing need for medical intervention and medication requirements (No Testis/Ovaries = Less exogenous hormones)
 * If, however, you look at satisfaction of outcome, you come to a lot of bias. Most of the reporting is done withing GID clinics, meaning there is observer bias. FTM transsexuals definately draw the short straw when it comes to genital surgery, with much being unsatisfactory in function, as well as being significantly painful. Apparently there is a high rate of Hysterectomy and oophorectomy in preference to genital surgery in FTMs. The flip side is they tend to get early access to mastectomy, and good response to Testosterone in terms of facial hair and voice (two things Transwomen wish hormones could alter for them). Genital surgery is generally considered more successful for FTMs, mostly because it is performed more often, and has been done for longer (on Intersex people to start with - it's easier to chop off a large "clitoris" than bulk up a small "penis" with "Hypospadias").
 * Satisfaction is related mostly to pain, function and complications. These can be addressed like most medical interventions with realistic and evidence-based counselling before treatment. But understandably, if you have a rectal-vaginal Fistula after your $20,000 surgery, you're going to be pretty pissed. Particularly if you also can't pee downwards. :P
 * Cheers!  Lauren  ♫/∆ 01:27, 27 March 2007 (UTC)

this is terrible
this article is about sex reassignment, not gender reassignment. it certainly needs to be renamed.

The more I think about it, the more I agree. I have gone ahead and renamed the page. To the person who posted the previous comment: if you happen to read this, please know to always sign your posts on talk pages by typing four tildes. Andrea Parton 06:20, 12 February 2006 (UTC)

Data on follow through
Is there any data on the percentage of people that follow through after beginning the trial of living as the opposite gender before the operation? It seems that it would be an interesting addition to this article. Vicarious 15:03, 12 September 2006 (UTC)
 * The commonly quoted percentage is about 97-99% complete the Real life test, although I can't find a Dead tree article on it. Certainly the incidence of detransition and "regret" is more often studied. Cheers!  Lauren  ♫/∆ 01:15, 26 April 2007 (UTC)
 * I just added some detail on it. It's covered as part of Reference 6, the Kuiper/Cohen-Kettenis study of 1998 - A l is o n  ☺ 04:50, 26 April 2007 (UTC)

Major rewrite
janniejdoe 21:43, 14 September 2006
 * This page needs a major re-write. Its contents are controversial, yet the discussion of the controversial aspects does not cite references. Some of the the sub topics fail to justify how they help explain the primary topic, instead they mention tangential controversy wihout satisfactorily connecting that controversy with the subject matter. For example, mention of the Reimer case does not contribute to the sub matter here. Another example would be failure to cite the actual Johns Hopkins articles, the evidence of their bias and lack of scientif rigor, or the various subsequent studies that refute the Johns Hopkins article, which is over 25 years old and out dated at best. Also few other topics on medical procedures spend so much time discussing external opinions about them made by religious extremists, who lack medication education. Those few might only be abortion and invitro fertilization.

Merge proposal
I'm proposing this merger because these sections claim the same name, yet aren't discussing the same things even though it appears they should be. Through a quick overview, it seems most appropriate to merge the Transsexualism section into this primary article; of course, leaving in place appropriate "quick" descriptions on the Transsexualism article. Let me know if I'm off my rocker. Thanks. Zue Jay (talk)  04:12, 5 March 2007 (UTC)
 * Agreed there and here - Shall we do it? Cheers!  Lauren  ♫/∆ 01:29, 27 March 2007 (UTC)
 * Merged what was sitting in my sandbox, the majority of which I reviewed. However, I have limited knowledge of these topics and how to correctly phrase certain things. Please, please, please review it carefully. Also, there is a lack of information in this newly merged article with regards to intersex individuals (right there I probably made a grammer gaff!); need to modify to better include. Zue Jay (talk)  19:05, 28 March 2007 (UTC)
 * Good merge, looks okay. Will review over the next week or so. Cheers!  Lauren  ♫/∆ 00:13, 2 April 2007 (UTC)

Men/women etc...
I know it's probably a prickly subject and one I know little about, but the following sentences seem to have the wrong sense to me:


 * For example, HRT can induce breast growth for transsexual women but cannot reduce breasts for transsexual men. HRT can prompt facial hair growth for transsexual men, but cannot regress facial hair for transsexual women.

Isn't it transsexual men who'd want to grow breasts, i.e. those people who are, genetically, male? Likewise for the other statements. While it may be that "Transsexual people almost universally prefer to be referred to by the gender pronouns and terms associated with their target gender", they are genetically not their target gender, and it seems to me that genetics (except in rare cases) is the one objective way of determining sex.

The transsexualism page suggests the use of "male-to-female transsexual" and "female-to-male transsexual" to avoid confusion. David 16:06, 28 June 2007 (UTC)

I am a woman but I look like a man, therefore I am a transsexual woman. After SRT I will still be a woman and look like a woman, therefore I will just be a (former transsexual) woman. —Preceding unsigned comment added by 92.201.26.150 (talk) 13:16, 24 July 2008 (UTC)

Dr Paul McHugh
The link on Dr. Paul McHugh's name on this page takes the user to a different Paul McHugh, a lawyer. 24.179.134.226 23:43, 27 August 2007 (UTC)
 * Rmv'd link. If someone knows if the correct McHugh is in Wikipedia, the correct wikilink would be appreciated. Zue Jay (talk)  00:45, 28 August 2007 (UTC)

Controversy and Weasel Words
Removed the sentences that had the unfulfilled citation requests (these requests had been up for a while). The first 2 paragraphs seemed to be worded weaselly and the weasel words seemed to persist as a theme throughout the section, so I added a "weasel" tag.

I also have some other issues with this section, because this is seemingly the only section/article in Wikipedia that discusses opposition to transsexuality in general outside the context of transphobia. Perhaps someone else can prove me wrong regarding this.

Cornince (talk) 00:34, 16 July 2008 (UTC)


 * Removed the weasel/peacock words.


 * Cornince (talk) 18:09, 21 July 2008 (UTC)

Citation Issues
Citations 2 and 3 does not exist, and citations 1 and 4 are from a web pages of dubious quality. I added the flag thingies up top. I don't really know how to wikipedia, but this is not what I expect when I look for information about a topic. 76.70.117.58 (talk) 14:37, 27 November 2012 (UTC)

This article needs a lot of work
I see weird citation practices, like (Brown 107), as well as just a general sloppiness. I'll pick here and there what I can, but I doubt I'd be able to seriously restructure this article. --Beneficii (talk) 03:35, 17 January 2014 (UTC)

As well, this article goes into a lot about whether GID is a really good term to describe transgender people who experience gender dysphoria, etc., which isn't really relevant. This article is about the course of therapy designed to treat what has been variously called GID (DSM-IV & ICD-9), gender dysphoria (DSM-5), and transsexualism (ICD-10). Perhaps we can work to make this article a little more focused on the treatment? --Beneficii (talk) 03:46, 17 January 2014 (UTC)

Controversy and diagnosis
The diagnosis section is a mess, so we would like to have experts assist, also by providing sources representing the current understanding in the field. As well, I think we need to be able to determine the relative weight of the various points of view on sex reassignment therapy, ranging from its being medically necessary to being flatly harmful. The way most opposition just got put into a "Controversy" section may violate WP:STRUCTURE, which states:

"Segregation of text or other content into different regions or subsections, based solely on the apparent POV of the content itself, may result in an unencyclopedic structure, such as a back-and-forth dialogue between proponents and opponents. It may also create an apparent hierarchy of fact where details in the main passage appear "true" and "undisputed", whereas other, segregated material is deemed "controversial", and therefore more likely to be false. Try to achieve a more neutral text by folding debates into the narrative, rather than isolating them into sections that ignore or fight against each other."

I think it would be really helpful to get some experts involved in this. With recent rulings in the States supporting the medical necessity of sex reassignment surgery, such as the one striking down the Wisconsin Inmate Sex Change Prevention Act, the ruling in the Kosilek case, and the ruling of the Departmental Appeals Board of the HHS saying Medicare's exclusion of SRS is not based on "complete and adequate" evidence, as well as the coverage for sex reassignment therapy provided in many other countries and the consensus statements by major medical organizations in the USA and elsewhere, it seems that it would be helpful to determine if a consensus on this matter has developed and to structure the article so as to comport with that consensus. --Beneficii (talk) 04:18, 17 January 2014 (UTC)


 * With access to reference texts, we have been able to determine the proper weight, according to WP:DUE, so I have taken down the call for experts. --Beneficii (talk) 23:20, 30 January 2014 (UTC)

undue weight
I think too much weight is given to the John Money case. This case is not relevant for sex reassignment theory of transsexual people.

As well, the Paul McHugh study, being a very old single study that has not been reproduced very much, and goes against what appears to be a growing consensus, may have been given undue weight as well. Also, there are signs at the time it was published it may have been given too much weight, as the U.S. Health and Human Services Departmental Appeals Board noted in its discussion that the aggrieved party had argued (before deciding the point was moot for the case in question):

"The aggrieved party also argues that the NCD when issued was invalid and unsupported by the NCD record. The aggrieved party argues that the 1981 NCHCT report acknowledged the effectiveness of transsexual surgery in stating that 'eight of the nine studies' that 'represent[ed] the major clinical reports thus far published' between 1969 and 1980 on the outcome of the surgery 'reported that most transsexuals show improved adjustment on a variety of criteria after sex reassignment surgery.' 7 NCD Record at 17­ 18. The aggrieved party also argues that the ninth, unfavorable, study on which the NCHCT relied was 'severely flawed and ideologically biased,' and criticizes two of the sources cited in the 1981 NCHT report as ideologically biased against transgender individuals, based on their published writings. AP Statement at 5."

Ruling on NCD 140.3, which excludes sex reassignment surgery

The James Beatrice study may come under this as well, being another single study that goes against the consensus, but I'd perhaps want to wait for someone more familiar to look at that.

The big studies are fine, but I think it would be better if we could determine if a consensus exists and, if so, to move toward representing that consensus primarily. Some of what I've mentioned, such as the APA Task Force report, as well as statements by major medical organizations in many parts of the world, suggest such a consensus may be forming, or at least a majority view. --Beneficii (talk) 06:05, 17 January 2014 (UTC)


 * I think including the John Money case is appropriate. If anything, it appears that we do not give enough mention to sex reassignment therapy performed on intersex people and people like David Reimer.  Not knowing very much about the topic, however, I am not sure how much help I could be of in this regard. --Beneficii (talk) 06:15, 17 January 2014 (UTC)

With the emphasis now on systematic reviews and statements from major health organizations in that section, the Undue tag has been removed. We could still use some help on the intersex/ambiguous genitalia section, however. --Beneficii (talk) 06:53, 19 January 2014 (UTC)

Changing "Controversy" to "Effectiveness"
I am changing the name of the "Controversy" section to "Effectivness," since that's what the section actually discusses. The section seems, correctly, not to give undue weight to laypersons who oppose sex reassignment therapy. (For the most part, I think we need to be moving away from lay sources and toward medical and psychological sources.) As well, I am going to begin the organizational process a little more, by splitting off the David Reimer case into its own section, "Sex reassignment of infants with ambiguous genitalia," while moving the rest into "Sex reassignment of transsexual persons," since that discussion dominates the section anyway. --Beneficii (talk) 16:23, 17 January 2014 (UTC)

Proposed reorganization
Folowing Beneficii's twitter ping I came on to this article and I think it's a mess, sorry. I can't fix all of it - notably the over-reliance on Brown, a 1996 work; there has been a lot of development since 1996. I propose starting with a reorg so parts are easier to fix. As the reorg is significant I'd prefer to discuss it in talk before going in and doing it, to avoid an edit war.

So, after leaving the intro untouched, I propose the following structure:

1. Eligibility 1.1 Diagnosing transsexualism (and this will have ICD and WPATH before US-specific DSM) 1.2 Requirements for different steps of treatment (most of the Requiremnets section moves here) 1.3 Infants with genital conditions (yes it's conmtroversial but if they at least were considered eligible it belongs here) 2. Psychological treatment 3. Hormone replacement therapy 4. Chest reconstruction surgery 5. Sex reassignment surgery (a very brief part referencing the main article on "Sex Reassignment Surgery") 6. Additional treatment (absent in current version - cover facial surgery, electrolysis, voice - I don't know all of it but at least have a place for it) 7. Effectiveness 7.1 In transsexual persons (keep medical references here; needs expansion about McHugh - I'll just go and do now, no need to wait for restructure on this) 7.2 In persons with genital conditions (not sure it should be just "infants") 8. Ethical and political response (here goes what governments pay for what, as well as Rome and Janice Raymond - who is probably the only one of that team whose view is notable enough to mention by name, as it's associated, rightly or not, with the US decision to cease Medicare coverage. I suspect Rush Limbaugh also goes here)

Ramendik (talk) 00:19, 19 January 2014 (UTC)


 * Thanks for the proposal. On the expansion of McHugh in the effectiveness section, wouldn't that violate WP:UNDUE?  As I understand, he has not been a particular influential leader in the field, at least not outside the United States.  Since his ending sex reassignment therapy at Johns Hopkins, many other countries have added coverage for sex reassignment therapy to their health plans, as well as Canadian provinces.  No major health organization seems to support his views.


 * In addition, I was actually considering contracting the effectiveness section (in transsexual persons), by removing the McHugh, James Beatrice, and possibly the 2010 Sweden studies for being only single studies that did not engage in any systematic reviews. I think the section should be limited to systematic reviews and statements from major health organizations, which would make the section more coherent as well as bringing it into line with the apparent consensus, that the medical literature on the whole supports the effectiveness of sex reassignment therapy, but the quality of the evidence has been generally low.  Adding a bunch of one-off studies and statements from individuals would seem to be according them undue weight relative to systematic reviews and statements from major health organizations, in violation of WP:UNDUE. --Beneficii (talk) 00:37, 19 January 2014 (UTC)
 * Also WP:VALID needs to be considered here. --Beneficii (talk) 00:42, 19 January 2014 (UTC)
 * Add a history section? But it might cross with the surgery article? And I'm really unsure about removing McHugh as that is a well known view Ramendik (talk) 01:23, 19 January 2014 (UTC)
 * Being well-known is one thing, and certainly in the history his views deserve mention. However, being well-known is not the same as having equal validity, as WP:VALID states (emphases added):
 * "While it is important to account for all significant viewpoints on any topic, Wikipedia policy does not state or imply that every minority view or extraordinary claim needs to be presented along with commonly accepted mainstream scholarship. There are many such beliefs in the world, some popular and some little-known: claims that the Earth is flat, that the Knights Templar possessed the Holy Grail, that the Apollo moon landings were a hoax, and similar ones. Conspiracy theories, pseudoscience, speculative history, or even plausible but currently unaccepted theories should not be legitimized through comparison to accepted academic scholarship. We do not take a stand on these issues as encyclopedia writers, for or against; we merely omit them where including them would unduly legitimize them, and otherwise describe them in their proper context with respect to established scholarship and the beliefs of the greater world."
 * I would go for discussing him in the history and/or cultural/ethics section. --Beneficii (talk) 02:24, 19 January 2014 (UTC)
 * I am doing what I said I would do, and that is to remove mention of McHugh's actions at Johns Hopkins (whose study showed evidence against), the James Beatrice study (evidence against), and the 2010 Swedish study (evidence for), because these were all single studies that did not engage in systematic review of the literature and are likely to have been part of systematic reviews of the literature. I am keeping in the 1998 clinical review because it was a major systematic review, I am keeping the University of Birmingham's studies in because they illustrate a major issue that has plagued research into sex reassignment therapy, the long-term followup study in Sweden (2011) showing that there is higher morbidity in post-op transsexual people than in the healthy population should also stay because of its unique findings over a long period of time and because it has done its own review of the literature, and of course the APA Task Force's findings and its important statement that more robust study designs may not be feasible for sex reassignment therapy and the APA's statements in support should also remain.  I think when you take out the noise of the individual studies and leave in the systematic reviews and statements from major health organizations, a clear consensus emerges, and the section reads much more coherent and concise.  With this all together, we might be able to add into the lead a statement like, "Systematic reviews show that low quality medical evidence, supplemented by a board clinical consensus, supports the efficacy of sex reassignment therapy.  More robust study designs for aspects of sex reassignment therapy may not be feasible."
 * Since you may want to make use of McHugh, since he has been influential among the lay opposition while not very influential in the medical community, I have left the paragraph mentioning him. Another issue with his mention under effectiveness is that the source comes from a non-medical personal website.  We may want to work on that, too.
 * In 1979, when Paul McHugh became chairperson of the psychiatric department at Johns Hopkins, he ordered the department to conduct follow-up evaluations on as many of their former transsexual patients as possible. When the follow-ups were performed, they found that most of the patients stated that they were happy as members of their target sex, but that their overall level of psychological functioning had not improved.  McHugh reasoned that to perform physical gender reassignment was to "cooperate with a mental illness rather than try to cure it."  At that time, Johns Hopkins closed its gender clinic and has not performed any sex reassignment surgeries since then.
 * --Beneficii (talk) 06:21, 19 January 2014 (UTC)
 * The source part is easy. Here is his actual full article. http://www.lhup.edu/~dsimanek/mchugh.htm It has the full text and mentions the source, which is "The _American Scholar,_ Autumn 1992." As it's a magazine of a "society for science and arts", not a peer reviewed scientific journal, it does belong in an ethics section. Also, McHugh has his own article and I am planning to wikify his name.
 * I am trying to decide whether to add a History section here, given that one is already available in "Sexual reassignment surgery". Historically, surgery has been the only available treatment, so while that article is limited to the modern Western definition and misses the feminizing castration practiced by Roman priests of Cybele or by some Indian Hijra, it might be better to put these into the History section of the surgery article?Ramendik (talk) 23:09, 19 January 2014 (UTC)
 * Good find. As for adding a history section, dunno.  It seems like there can be some redundancy in WP, but I think perhaps we should aim for more general information here, with more specific information for each procedure on their own pages.
 * As for Paul McHugh, I think that's a good idea. I think with Paul McHugh's views that sex reassignment is invariably harmful, it's the same as with surgery-on-demand: Neither idea has much support in the medical literature, and secondary and tertiary sources don't seem to give either idea much if any weight.  We should look to move that to the non-medical section.  Surgery-on-demand is a popular view among trans people, but I wonder who we can cite for that. --Beneficii (talk) 02:49, 20 January 2014 (UTC)
 * Apart from weight of ideas in medical theory, there is the practical side. The McHugh view may have a minimal impact in the professional world in the narrowly-defined Western world but there is more to the world and psychiatry than the West. And the on-demand view translates into loads of personal actions when medical theory demands seeing a doctor first - even in Western Europe where the availability of the doctor is much less of an issue (as in you wait months, not save for years). The practical impact alone creates notability in my view, so the question is where you place the information - and for the on-demand view, how you substantiate it.Ramendik (talk) 05:16, 20 January 2014 (UTC)


 * Good question. I think McHugh may affect the payment policies of countries (i.e. make it more difficult for people to get treatment in those countries), such as the U.S.  Now, surgery-on-demand as I understand it is not followed in Thailand anymore because in 2009 the military government ordered that patients must have been on Real Life Experience for at least a year and to have been evaluated by 2 mental health professionals (and I think have been on hormones as well).  I think we should do it like this, for both of them; if there are secondary and tertiary medical or psychological sources supporting either of them, then they should be placed under the "Effectiveness" section with the other medical/psychological evidence.  Otherwise, it seems they would belong in the cultural/ethical section. --Beneficii (talk) 06:28, 20 January 2014 (UTC)

Definition of transition
A statement in the intro said: "Most trans people simply call this process transition." If this stateneet was true as written, this article and Transitioning (transgender) would be merge candidates. I do not, however, think the statement is true. "Sex reassignment therapy" covers only the medical part (including psychological treatment), but "transition" also involves personal and social changes that are not medical in nature; moreover some people transition without medical interference, although it might be a rare situation. I have modified the statement and hope it's ok now. Ramendik (talk) 00:02, 20 January 2014 (UTC)

Unsubstantiated statements - do they need sources and which sources?
There are statements in the article regarding opinions of certain trans people. While I know from the debate context that they are true, they are unsubstantiated in the article, and honestly seem like WP:WEASEL to me.

I do wonder if they have to be substantiated and if so, how - the are about opinions but linking to blogs stating opinions might not work for Wikipedia. Perhaps look for popular articles or interviews? I'm not very experienced in Wiki editing so before going and adding references I'd like to ensure what kind of references would work.

In the meantime I am listing the statements here, so that once the principles are clear I or someone else can look for sources. I don't want to vandalize the article with loads of "citation needed" notes, so just quoting here.

"Most trans people call the process of adjusting their bodily and social appearance to their preferred gender, which often includes sex reassignment therapy, transition." (I edited this one, but the "most trans people" part was already there).

Then loads in the diagnosis section:

"Many transgender and transsexual activists, as well as many caregivers, state that health and health-related problems are not usually related to the gender identity issues themselves, but to problems that arise from dealing with a gender identity that does not match an assigned gender role and the related social conflicts. Many feel that the health-related problems from the gender identity conflict are much more likely to be diagnosed in transsexual people than in the general population. Transsexual people are usually required to visit a mental health professional to obtain approval for hormones and sex reassignment surgery, thus exposing the transsexual community to a higher level of evaluation for mental health issues than the general populace." This paragraph make slots of statements and has at least two cases of apparent WP:WEASEL with no citations at all.

"Some transsexual people have pressured the American Psychiatric Association to remove Gender Identity Disorder from the DSM. Many of these people feel that at least some mental health professionals are being insensitive by labeling transsexualism as "a disease" rather than as an inborn trait.[citation needed] Furthermore, many people have expressed concerns that in viewing transsexualism as "a disease" some psychologists and psychiatrists have sought to develop specific models of transsexualism such as Ray Blanchard's model, which may exclude many transsexual people." - it already has one "citation needed" but what kind of citation should we provide here? The second part is, really, also "citation needed".

Really, if there are no *medical* sources for these objections to the diagnosis, I think they might belong in the ethics/cultural section once the reorg is done (I'm still holding reorg work off in case someone has additional ideas). Though opinions cited are those of trans people, if they are not medical, in an article on medical issues they belong in ethics/cultural, right? (Does not apply to "transition" in intro as terminology does belong in intro).

"A more modern idea suggests that the focus on surgery status is misplaced, and therefore, an increasing number of people are refusing to define themselves in terms of operative status, often defining themselves based on their social presentation instead. Many transsexual people believe that SRS is only a small part of a complete transition." - hello WP:WEASEL again? What sources *can* we cite? And, cultural again? (but then "preop/nonop/postop" porbably belong in cultural too, not being medical terms).

"Most US professionals who provide services to transsexual women and men follow the controversial Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People put forth by the World Professional Association for Transgender Health." - the word "controversial" without a citation does not seem right here.

"A significant and growing political movement exists, pushing to redefine the SOC, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted" - two movements are claimed to exist but no citations are given.

"Some doctors are willing to prescribe hormones to any patient who requests them; however, most physicians are reluctant to do so, especially for trans men. In trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result. Some transsexual men and women are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves." As long as the text departs from the SoC, citations disappear. (SoC part is somewhat dated as WPATH 7th ed is out, but I'll get to it at reorg time).

"Some surgeons who perform sex reassignment surgeries may require their patients to live as members of their target gender in as many ways as possible for a specified period of time, prior to any surgery. However, some surgeons recognize that this so-called real-life test for trans men, without breast removal and/or chest reconstruction, may be difficult. Therefore, many surgeons are willing to perform some or all elements of sex reassignment surgery without a real-life test. This is especially common amongst surgeons who practice in Asia. However, almost all surgeons practicing in North America and Europe who perform genital reassignment surgery require letters of approval from two psychotherapists; most Standards of Care recommend, and most therapists require, a one-year real-life test prior to genital reassignment surgery, though some therapists are willing to waive this requirement for certain patients. A recent study done on trans women has shown that a real-life test of less than one year, or no real-life test at all, does not increase the likelihood that a patient will regret genital reassignment surgery.[11] Many transsexual people opt for a real-life experience longer than is officially required, to remove any doubts they may have of whether they should undergo surgery or for financial reasons." - the only citation is a study by Anne Lawrence, and all the policies of "some surgeons" are not supported by any citations. But *can* they be supported? Surgeons are not likely to publish their policies? What can be quoted here - someone's investigative journalism? Guideline sites like http://ai.eecs.umich.edu/people/conway/TS/SRS.html ? (This page would substantiate the statement about surgeons in Asia, but is it a proper source?) Ramendik (talk) 00:43, 20 January 2014 (UTC)


 * Thanks for taking a look at it. There's a lot to consider, but it seems much of it can be answered by the new SOC.  For example, on the mammectomy for trans men, the SOC (p. 201) does not require real-life experience, neither does it seem the UK RC-Psych standards (p. 23).  Of course, other countries may still have other issues on this, but for me web-based resources for transition in most countries is difficult to find.


 * As for some not thinking surgery is important, I do believe that there is an increasing majority view, at least, that sex reassignment therapy should be tailored to the individual. Here is the SOC v7 on it (p. 199): "While many transsexual, transgender, and gender-nonconforming individuals ﬁnd comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage & Karim, 2000)."


 * As for the statement in the lead about it being called transition probably isn't a problem, because I don't think it's likely to be challenged; if it would become apparent from studying the body of the text (probably including the sources), then it's generally OK, per WP:LEAD. Elsewhere, though, we need to find support for the weasel statements, I think.


 * Some of the other statements I'm not so sure about, to be honest. If I think about it, I might think of more things.  I will, however, go ahead and add the SOC v7 to the bibliography at the bottom of the page. --Beneficii (talk) 02:37, 20 January 2014 (UTC)


 * I'm mostly worried about the "depathologize"/"service on demand"/"no gatekeeping at all" model of transition. I disagree with it but that's not what is important; what is important is how this position, and the ways treatment can be obtained under it - Asian surgeons, informed-consent hormone clinics, online hormone purchase - is to be described and referenced. Remember, there are real people reading this article, some of whom are directly affected. In line with NPOV that position, which has a big theoretical following and a significant practcal one, should be presented with appropriate references and appropriate weight, not just as mysterious "some people". The obvious approach is to place it in ethics/cultural... Or perhaps - just have this idea - give "treatment outside SoC" a separate heading? But as this entire thing is not approved by Western medicine, scientific sources are not available. Are activist and personal sites to be used as sources at all?
 * As an aside do you have a link to the UK RC-Psych standards? Ramendik (talk) 05:10, 20 January 2014 (UTC)


 * reference no. 4 on the page. --Beneficii (talk) 06:23, 20 January 2014 (UTC)


 * This is the source for Thailand tightening sex reassignment surgery criteria: http://www.telegraph.co.uk/expat/expatnews/6669101/Thailand-tightens-sex-change-laws.html --Beneficii (talk) 06:43, 20 January 2014 (UTC)


 * Alas, I show my own Western bias here. Nevertheless, we can try to include the experiences of, say, the Hijra in India, as well as the experiences in other countries. --Beneficii (talk) 07:06, 20 January 2014 (UTC)


 * Found an example - would this article be a valid source? It is not a personal blog but a real newspaper, yet the author is apparently an activist. http://www.huffingtonpost.com/jack-harrison/international-day-of-action-for-trans-depathologization_b_4118023.html Ramendik (talk) 05:20, 20 January 2014 (UTC)


 * How about this University page? It gives a voice to each side in the debate on this matter.  http://academic.udayton.edu/CatherineLutz/Is%20Gender%20Identity%20Disorder%20An%20Appropriate%20Diagnosis.pdf  Unfortunately, it does not make clear what book it is referencing.  Here is another source that wants depathologization, an essay written for an LGBT center at University of Rhode Island.  What do you think of it? http://digitalcommons.uri.edu/cgi/viewcontent.cgi?article=1030&context=glbtc  I wonder which sources look for depathologization in the ICD. --Beneficii (talk) 06:39, 20 January 2014 (UTC)
 * I did some further reading on Wikipedia polices, and looks like much of what I marked as WP:WEASEL can indeed be substantiated by blog/activist sources, citing WP:ABOUTSELF. I mean, if we wrtie "many activists believe" it seems to be OK to cite an activist or two, because they are sources about their own activism. Of course such claims should be clearly separate from medical. I hope to get to the reorg in teh coming days and this will include the ethical/cultural heading where this information is appropriate.Ramendik (talk) 00:11, 28 January 2014 (UTC)


 * Sounds great! --Beneficii (talk) 22:13, 28 January 2014 (UTC)

future directions for the article
I'm thinking of some of the issues with this article. Here are some ways I think they may need to be resolved:


 * 1) It looks like this article isn't going to do much for the intersex community, so it may just be worth it to make the article purely about transgender treatment.  Plus, I think the article on sex assignment deals more specifically with issues relating to intersex persons.
 * 2) Since there are already specific articles on each individual procedure (viz. psychotherapy, hormonal therapy, sex reassignment surgery), it seems like we could simply summarize each one and give a hotlink to each individual article.  This article could instead focus on matters of the efficacy/effectiveness and of cultural and ethical views of sex reassignment therapy in general, while the individual articles may refer more to their own specific issues.
 * 3) Is sex reassignment therapy the best name for this article?  Perhaps something more general like, "treatment for gender identity disorder" could be better.

I wonder what the other editors here think of this? --Beneficii (talk) 06:58, 29 January 2014 (UTC)

I could also add a fourth concern:


 * This article may not distinguish between the different issues for children, adolescents, and adults enough, whereas reliable sources tend to. --Beneficii (talk) 07:20, 29 January 2014 (UTC)

An important difference?
I wrote this sentence in the lead:


 * as well, there exists a broad clinical consensus, supplementing the academic research, supporting the effectiveness of sex reassignment therapy in appropriately selected patients.[7]:2-3

The source is the APA Task Force report. In question is specifically the statement "...supporting the effectiveness of sex reassignment therapy,..." At first, it seemed a no-brainer to add, as that seemed to be the gist of what the section is seeing, and it would be in line with the other secondary sources.

Perhaps I'm nitpicking, but the main statements used in support of that quote, which fall under the executive summary section, are as follows:


 * The Task Force concludes that the current credible literature is adequate for the development of consensus-based treatment recommendations for all subgroups reviewed. Moreover, with subjective improvement as the primary outcome measure, it is concluded that for adults sufficient evidence exists for the development of recommendations in the form of an APA practice guideline, with gaps in the research database filled in by clinical consensus. (p. 2)


 * The Task Force recommends that additional steps be taken by the APA pertaining to issues relating to GV (Appendix I) and to DSDs, whether or not GV is an issue (Appendix II). These include issuing a position statement to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments for minors with GID, and the rights of persons of any age who are gender variant or transgender. (pp. 2-3)



Now what on earth could they mean by treatments? It's pretty clear from the context of the report, from the recommendations for "transgender health care" in Appendix I, and from the subsequent position statement issued by the organization that they are referring to sex reassignment therapy. It seems to be common sense, per WP:COMMON, but someone could come along and say understanding that from the context could constitute WP:SYNTHESIS, so I'm confused. Could the statement stay as it is, or perhaps should it be modified to say something like "supporting treatment recommendations," which could have the negative effect of befuddling the reader as to what the APA Task Force was talking about? --Beneficii (talk) 07:12, 29 January 2014 (UTC)


 * Oh fooey. The statement on pp. 2-3 points the reader directly to Appendix I, which mentions "transgender health care" and the forthcoming position statement.  I am convinced that the source verifies the statement. --Beneficii (talk) 07:14, 29 January 2014 (UTC)


 * There's also WP:SYNTHNOT to keep in mind. (I'm still learning.)  Especially relevant are "SYNTH is not summary" and "SYNTH is not explanation."  Perhaps the statement could still be improved, however. --Beneficii (talk) 07:19, 29 January 2014 (UTC)


 * And specifically about effectiveness, there are other statements from that APA Task Force report (first external link in this section) supporting it:


 * While the existence of the diagnosis contributes to the stigma of affected individuals, the unintended result of the APA's silence is a failure to facilitate full access to care for those diagnosed with GID. The Task Force, therefore, recommends that the APA consider drafting a resolution, similar to Resolution 122 of the American Medical Association (62). This resolution concludes that medical research demonstrates the effectiveness and necessity of mental health care, hormone therapy and sex reassignment surgery for many individuals diagnosed with GID and resolves that the AMA supports public and private health insurance coverage for medically necessary treatments and opposes categorical exclusions of coverage for treatment of GID when prescribed by a physician. (p. 9)


 * Perhaps this page also needs to be referenced to make clear that the source validates the statement? --Beneficii (talk) 07:38, 29 January 2014 (UTC)