Transgender Healthcare

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Introduction

This article provides an overview of the treatment options available to help transgender and gender diverse (TGD) adults with gender dysphoria. This article requires a basic understanding of the terminology used by the transgender community. For more information, check out this helpful Geeky Medics LGBTQ+ terminology guide.

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Background

Gender incongruence

In the 2021 census, approximately 262,000 people in England and Wales (0.5% of the population) reported that their gender identity differed from their sex registered at birth. This number includes trans men, trans women, and non-binary people.¹ Due to underreporting, it is likely that the true prevalence may be even higher.

The ICD-11 defines Gender Incongruence of Adolescence and Adulthood (HA60) as a ‘marked and persistent incongruence between an individual’s experienced gender and their assigned sex’, replacing outdated terms such as ‘transsexualism’ and ‘gender identity disorder’.²

Gender dysphoria

Despite being in the ICD-11, the term gender incongruence is not widely used by the general public. TGD people more commonly use the term gender dysphoria to describe the emotional distress (such as depression, self-hatred, or anxiety) that arises due to the mismatch between their experienced gender identity and assigned biological sex.³ For simplicity, it is often useful to think of gender dysphoria as a symptom of gender incongruence.

Dysphoria is a complex and subjective emotional response that is not yet fully understood. It is thought to be influenced by multiple factors, including previous life experiences, societal expectations, cultural gender roles, and a person’s view of their own body.⁴

This means that one person’s experience of dysphoria may differ from another person’s experience, and not all TGD people experience all types of dysphoria towards every aspect of their bodies. For example, one person may experience distress, hatred, or disgust towards their genitalia; whereas another person may feel ambivalent towards their genitalia but experience strong feelings of dysphoria towards their voice and the way it causes them to be perceived by others.

Dysphoria can share clinical features with mental health conditions such as depression, anxiety and body dysmorphia (more information in the ‘gender incongruence and mental health’ section below).⁵

Many TGD people also use the term gender euphoria to describe positive emotional responses (such as happiness, calmness, or inner peace) which arise from experiences which align with their gender identity.⁶ Euphoria, much like dysphoria, is a complex subjective emotional response that can be influenced by social and cultural factors. For simplicity, gender euphoria is often described as the opposite of gender dysphoria. Gender euphoria can, therefore, also be conceptualised as a symptom of gender incongruence.

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Referral to a gender dysphoria clinic (GDC)

Adult NHS gender affirming care is currently managed by seven specialist gender dysphoria clinics (GDC) in England, four specialist GDCs in Scotland, and one specialist GDC in Wales.⁷ If a patient tells you they are transgender, they should be referred to a GDC without any delay.

The GDCs are national services which can accept patients from anywhere in that country, meaning any healthcare professional can refer any TGD person in England to any GDC in England. Currently, a TGD person in England cannot be referred to a GDC in Scotland or Wales, and vice versa. Clinicians should discuss with patients to agree the most suitable GDC, considering travel distance and up-to-date waiting times. Patients can also choose to self-refer to any GDC.⁸

The GDC can interview patients, review blood tests, give prescribing advice for gender affirming hormone treatment (GAHT), refer to voice and communication therapy, and refer to specialist centres for gender affirming surgeries. Note that the GDC reviews test results and gives prescribing advice, but the GP is typically responsible for prescribing hormones and organising blood tests (more information in the ‘medical management’ section below).

Table 1. NHS gender dysphoria clinics. Waiting time data correct as of January 2024.⁹

Clinic name	Mean time from referral to first appointment (months)	Mean time from referral to GAHT (months)
The Tavistock and Portman NHS Foundation Trust GDC	60	70
Sheffield Health and Social Care NHS Foundation Trust GDC	62	78
Leeds and York Partnership NHS Foundation Trust GDC	57	67
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northern Region GDC	62 Not accepting new patients	109 Not accepting new patients
Northamptonshire Healthcare NHS Foundation Trust GDC	53	62
The Nottingham Centre for Transgender Health	23	34
Devon Partnership NHS Trust West of England Specialist GDC	87	99
Glasgow Sandyford GDC	55	Not reported
Lothian Edinburgh Chalmers GDC	23	Not reported
Grampian Aberdeen Cornhill GDC	24	36
Highland Inverness Raigmore GDC	29	Not reported
Welsh Gender Service	15	25

As you can see from the table above, the existing GDC model is struggling to meet demand, resulting in long waiting lists that exceed the NHS’s 18-week maximum target.¹⁰

In addition to the seven specialist GDCs in England, there are several clinics with alternative delivery models, such as Indigo in Manchester (primary care integrated model), CMAGIC in Merseyside (primary care integrated model)I, and Trans Plus in London (sexual health clinic integrated model).

NHS England has commissioned these clinics to explore potential alternative healthcare delivery models that can meet the increasing demand for gender dysphoria services. At the time of writing, these clinics are mostly in the pilot stage, meaning they can only accept a limited number of patients from a prespecified geographical area.

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Gender incongruence and mental health

Gender incongruence is no longer considered a mental or behavioural disorder by the world health community.^4,11,12 The ICD-11 instead categorises gender incongruence in the section for ‘conditions relating to sexual health’.² TGD people therefore do not need to undergo a mental health assessment before being referred to a GDC for gender affirming care.

Many TGD people don’t have mental health concerns. However, mental health concerns may arise as a consequence of, or co-exist alongside, gender incongruence.

For example, a 2023 meta-analysis reported higher levels of eating disorder symptomatology amongst TGD individuals compared to cisgender individuals, which was shown to improve following gender affirming care.¹³ Similarly, a 2018 meta-analysis found that TGD people experienced significantly worse mental-health-related quality of life compared to matched cisgender controls, which improved following GAHT.¹⁴

TGD patients with mental health concerns or substance use disorders may benefit from the support of a specialist mental health practitioner alongside their gender affirming healthcare.¹¹ Mental health symptoms that do not affect a person’s capacity to consent, such as anxiety or depression, do not prevent them from receiving gender affirming treatments.¹¹

Severe mental health symptoms that directly impair a person’s capacity to consent, such as psychosis, should be addressed to restore the patient’s capacity before initiating gender-affirming treatment.¹¹ Existing GAHT should be maintained if possible in cases where a TGD individual’s mental health deteriorates, and the underlying cause for their deterioration should be investigated.¹¹

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Medical management

Sex hormones (oestrogen and testosterone) are produced by the gonads (ovaries and testes). During puberty, these sex hormones act on tissues throughout the body to cause the development of secondary sex characteristics.

Table 2. Secondary sex characteristics. 

Examples of female secondary sex characteristics	Examples of male secondary sex characteristics
Breasts Body fat distributed to the hips and thighs Wider pelvis Menstruation Craniofacial features such as a less prominent chin	Deeper voice Body fat distributed to the abdomen and trunk Male pattern hair loss Facial hair Craniofacial features such as a more prominent supraorbital ridge15

Gender affirming hormone treatment (GAHT) aims to align a person’s body more closely with their gender identity. An exogenous sex hormone should be prescribed to promote the development of secondary sex characteristics which align with the person’s gender identity:

• Oestrogen can be prescribed to promote the development of female secondary sex characteristics
• Testosterone can be prescribed to promote the development of male secondary sex characteristics

The prescribed sex hormone exerts negative feedback onto the Hypothalamic-Pituitary-Gonadal (HPG) axis, which automatically suppresses the patient’s endogenous sex hormone production.

Suppressing endogenous sex hormone production can beneficially reduce secondary sex characteristics which do not align with the person’s gender identity. If the patient does not experience sufficient suppression of their endogenous sex hormone (e.g. serum testosterone > 3 nmol/L in a trans woman), then a ‘hormone blocker’ medication should be added to their regimen.

Medications to block testosterone are commonly indicated for trans women, but medications to block oestrogen are less common for trans men (prescribing testosterone exerts a strong automatic supersession effect on endogenous oestrogen production). Hormone blockers are not necessary if the testes or ovaries have been removed.

For example, a transgender woman (a person who identifies as feminine but was assigned male at birth) would be prescribed a ‘hormone blocker’ to reduce testosterone production from her testis, as well as exogenous oestrogen to cause the development of female secondary sex characteristics which align with her gender identity. We will discuss this in more detail below.

Similar to cisgender puberty, it takes approximately three years for the full effects of GAHT to become visible.¹⁶

Masculinising GAHT

Masculinising hormone treatment aims to promote the development of male secondary sex characteristics in cases where this is appropriate to help a person’s body more closely align with their gender identity. Masculinisation is achieved by administering testosterone. 

Table 3. The effects of testosterone

Effect	Time to onset	Time to maximum effect
Thicker skin and increased sebum production (this may cause acne, which can be distressing to patients and may require additional management)	1-6 months	1-2 years
Clitoral enlargement	1-6 months	1-2 years
Body fat redistribution from the hips and thighs to the abdomen and trunk, creating a more ‘masculine’ body shape	1-6 months	2-5 years
Decreased subcutaneous fat	1-6 months	2-5 years
Menstrual cessation which may impair fertility *	1-6 months	Undefined
Thickening of the vocal cords, resulting in a deeper vocal pitch	6-12 months	1-2 years
Increased muscle mass	6-12 months	2-5 years
Increased body hair and facial hair growth	6-12 months	4-5 years
Male-pattern hair loss †	6-12 months	Can continue indefinitely

* Testosterone alone is not sufficient for fertility control, even if periods have stopped. Patients should be advised on best practices for effective contraception if they are at risk of unplanned pregnancy.¹⁶

^† Prevention and treatment as recommended for biological males.

Testosterone can be administered as a transdermal patch, transdermal gel, or intramuscular injection. The dose should be increased or decreased until a plasma testosterone concentration within the specified target range is achieved (more information in the ‘ongoing monitoring’ section below).¹¹

Different forms of testosterone have different target concentration ranges. For example, the target concentration range is different for a short-acting testosterone injection compared to a long-acting injectable testosterone or a testosterone gel.

Feminising GAHT

Feminising hormone treatment aims to promote the development of female secondary sex characteristics in cases where this is appropriate to a person’s body more closely align with their gender identity. Feminisation is achieved by administering oestrogen.

Table 4. The effects of oestrogen.

Effect	Time to onset	Time to maximum effect
Decreased libido	1–3 months	3–6 months
Decreased spontaneous erection frequency	1–3 months	3–6 months
Decreased muscle mass	3-6 months	1-2 years
Body fat redistribution from the abdomen and trunk to the hips and thighs, creating a more ‘feminine’ body shape	3-6 months	2-3 years
Thinner, softer, less oily skin with increased subcutaneous fat	3-6 months	Unknown
Breast development	3-6 months	2-3 years
Decreased testicular volume	3-6 months	2-3 years
Decreased sperm quantity and quality, which may impair fertility *	Unknown	>3 years
Decreased body hair and facial hair growth †	6-12 months	4-5 years

* Oestrogen alone is not sufficient for fertility control. Patients should be advised on best practices for effective contraception if they are at risk of unplanned pregnancy.¹⁶

^† Oestrogen alone cannot eradicate facial hair growth. If the person has already developed adult masculine facial hair, alternative methods such as laser hair removal or electrolysis can be provided by the NHS.

Oestrogen can be administered as oral tablets, transdermal gel, or transdermal patches. Evidence suggests that transdermal oestrogen administration is associated with a slightly lower risk of venous thromboembolism (VTE) compared to oral administration.¹⁶ Transdermal gels or patches are therefore the preferred forms of oestrogen, especially for patients aged > 45 years at higher VTE risk.¹¹

The dose should be increased or decreased until a plasma oestrogen concentration within the 400-600 pmol/L target range is achieved (see the ‘ongoing monitoring’ section below).¹¹

Hormone blockers

Prescribed sex hormones exert negative feedback onto the Hypothalamic-Pituitary-Gonadal (HPG) axis. This means that masculinising or feminising GAHT causes some automatic suppression of the patient’s endogenous sex hormone production (described in more detail above).

If the patient does not experience sufficient suppression of their endogenous sex hormone (e.g. serum testosterone > 3 nmol/L in a trans woman), then a ‘hormone blocker’ medication should be added to their regimen. Hormone blockers are not necessary if the testes or ovaries have been removed.

Several types of hormone blockers are used by the NHS, including Triptorelin, Leuprorelin, and Goserelin. These all belong to a class of drugs known as gonadotrophin releasing hormone analogues (GnRHa).

GnRH analogues cannot be taken orally and must be administered via an implant, subcutaneous injection, or intramuscular injection, typically performed by a nurse or GP. The effects are non-permanent and completely reversible, which is why hormone blockers have to be readministered regularly.¹⁶

Table 5. Overview of GnRH analogues.

Drug name	Administration route	Dose	Frequency
Triptorelin	IM	11.25mg	Once every 12 weeks
	SC or IM	3mg, 3.75mg	Once every 4 weeks
Leuprorelin	SC or IM	11.25mg	Once every 12 weeks
	SC	3.75mg	Once every 4 weeks
Goserelin	SC	10.8mg	Once every 12 weeks
	SC	3.6mg	Once every 4 weeks

Gamete storage

GAHT can cause reduced fertility, which may be permanent. TGD adults should be offered gamete cryopreservation before initiating oestrogen or testosterone treatment.^11,17

The NHS currently stores gametes up to 55 years.¹⁸ In some patients, GAHT does not cause total fertility loss and is not sufficient to prevent unwanted pregnancy. Patients should be advised on best practices for effective contraception if they are at risk of unplanned pregnancy.¹⁶

Ongoing monitoring

GAHT is typically a lifelong medication regime, as TGD patients are unable to produce their own sex hormones. Hormone dosage should be adjusted to achieve a concentration within the normal adult range associated with the individual’s gender identity.¹¹ This requires regular blood tests to determine the patient’s current hormone concentrations.

Table 6. Ongoing monitoring for GAHT.

	Target serum Testosterone range	Target serum Oestrogen range
Masculinising GAHT	Example: 8 – 19 nmol/L*	< 70 pmol/L (ref)
Feminising GAHT	< 1 nmol/L	400 – 600 pmol/L

*Exact target range can vary depending on the testosterone preparation being used. Consult local prescribing policy for more specific guidance. GDCs can also provide general prescribing advice.

Haematocrit (or haemoglobin) concentration should also be monitored for any TGD person treated with testosterone.¹¹ The GDC may request additional monitoring tests such as:

• Prolactin, lipids and LFTs for trans women
• FBC, SHBG and LFTs for trans men

Blood tests should be performed 6 weeks after any hormone medication or dose change and every 6-12 months once hormone concentrations are within the target range.

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Additional support

GPs have a responsibility to inform TGD patients about available services, and should support anyone seeking to access these services

Name and pronouns (aka. social transition)

Individuals may change their name and pronouns to align with their gender identity. This is often the first step TGD people take, but it is not required before making a GDC referral.

Patients can request to change their details at any time and do not need to have undergone any form of gender affirming treatment to do so.¹⁹ Updating a patient’s name on the electronic records system is easy to do and follows the same procedure as other types of name changes, such as after marriage. The patient’s previous name should be removed from all records.

Updating a patient’s registered gender, title, and pronouns involves the creation of a new patient record with a new NHS number. Practices must complete the new registration within five working days of the request to ensure there is no interruption to patient care.¹⁹

The current NHS system only supports male or female patient registration, which can be very frustrating for non-binary and gender diverse individuals. In these cases, clinicians are advised to make reasonable adjustments in collaboration with the patient, such as adding an alert to the patient’s notes.

Screening

Creating a new patient record with a new NHS number (see above) may affect the patient’s access to certain gender-specific NHS screening programs. For example, trans men who are registered as male will not be automatically invited for cervical screening even though they have a cervix and are at risk of cervical cancer. Similarly, trans women who are registered as female will not be automatically invited for prostate screening even though they have a prostate and are at risk of prostate cancer.

This flaw highlights the need for more comprehensive and inclusive screening protocols and administrative systems in the NHS. Addressing this issue is crucial to promote equitable access to healthcare services. Until this issue is resolved, GPs are advised to take a proactive approach to ensure their TGD patients are invited for appropriate screening.

Voice and communication therapy

Listeners often categorise voices as masculine or feminine based on pitch, timbre, and intonation. For example, low-pitched voices are typically perceived as masculine, whereas high-pitched are typically perceived as feminine.²⁰

Some of the differences between male and female voices occur because adult male vocal cords are typically thicker and longer than adult female vocal cords due to irreversible growth caused by testosterone during puberty (known colloquially as a ‘voice drop’). For some TGD individuals, ensuring their voice aligns with their gender identity is essential to be perceived correctly and feel safe in public places.¹¹

Testosterone can lower vocal pitch, but oestrogen cannot raise vocal pitch. Therefore, TGD people who feel that a feminine voice more closely aligns with their gender identity may require voice and communication therapy or vocal feminisation surgery if they have been exposed to testosterone (e.g. a TGD person who was assigned male at birth and transitioned after male puberty).

Gender affirming voice and communication therapy is the first-line option provided by the NHS to help TGD people change the pitch and timbre of their spoken voice without medical or surgical intervention.²¹

Gender affirming voice and communication therapy and vocal surgery are typically not required for patients receiving masculinising hormone treatment, as testosterone causes the vocal cords to thicken, resulting in vocal masculinisation.

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Surgical management

Some gender-related physical characteristics, such as a person’s genitalia or breasts, cannot be addressed using hormone treatment and instead require surgical intervention.

Gender affirming surgeries aim to align a person’s body more closely with their gender identity. A person’s decision to have gender affirming surgery is independent of their decision to have gender affirming hormone treatment (GAHT). It is important to remain mindful of the fact that a person is not ‘less transgender’ or a ‘less serious case’ if they have not undergone, or don’t want to undergo, gender affirming surgery.

Chest surgery (aka. top surgery)

Masculinising chest surgery typically involves a double mastectomy, whereby the breast tissue is removed to create a flatter and more masculine chest. Masculinising GAHT does not reduce breast size, meaning masculinising chest surgery is currently the only permanent solution for masculine-identifying TGD people who have developed breast tissue. Masculinising chest surgery is routinely performed by the NHS.

Feminising chest surgery typically involves a bilateral breast augmentation, whereby fat tissue or silicone implants are added to create a fuller and more feminine chest. Feminising GAHT does cause breast growth; however, TGD people may seek feminising chest surgery if they feel their achieved breast growth is insufficient. Feminising chest surgery is currently not performed by the NHS, but there are several private providers in the UK.

Genital surgery (aka. bottom surgery)

Masculinising surgery

Masculinising genital surgery encompasses several reconstructive procedures which aim to produce functional male genitalia to align a person’s body more closely with their gender identity.²²

• Phalloplasty: constructing a penis using skin grafted from the forearm, thigh, abdomen or back. The urethra may be relocated to facilitate urination whilst standing. Implants can be used to simulate an erection and give the penis sufficient rigidity for penetrative sex.
• Metoidioplasty: constructing a penis using clitoral tissue. Metoidioplasty is less invasive than phalloplasty but can only be performed if the patient has experienced sufficient clitoral enlargement due to masculinising GAHT.
• Scrotoplasty: constructing a scrotum using tissue taken from the labia majora. Silicone implants can be added to simulate testes. Scrotoplasty is typically performed in conjunction with a phalloplasty or metoidioplasty.
• Hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the ovaries and fallopian tubes) can be performed as individual procedures or in combination with the options listed above. GnRHa ‘blocker’ medications are no longer required after a salpingo-oophorectomy.

Feminising surgery

Feminising genital surgery encompasses several reconstructive procedures which aim to produce functional female genitalia to align a person’s body more closely with their gender identity.²² Note that GnRHa ‘blocker’ medications are no longer required after feminising genital surgery if the testes are removed.

• Vaginoplasty: constructing a vulva and vagina using tissue taken from the scrotum and penis. The testes are removed, and the urethral opening is relocated to allow urination from a sitting position. The resulting genitalia is aesthetically identical to that of a cisgender woman, and can be used for penetrative vaginal sex.
• Vulvoplasty (aka. “zero depth” vaginoplasty): constructing a vulva without a vaginal canal. Vulvoplasty is less invasive than vaginoplasty, but can only be performed if the patient does not wish to engage in penetrative vaginal sex. The testes are removed, and the urethral opening is relocated to allow urination from a sitting position. The resulting external genitalia is aesthetically identical to that of a cisgender female.
• Penectomy: removing the penis and testes to leave a featureless genital area which may be preferred by some androgynous, non-binary and gender diverse people. The urethral opening is relocated to allow urination from a sitting position.

The NHS performs all types of masculinising and feminising genital surgery. Before vaginoplasty, some patients may need hair removal on the genital skin. Before phalloplasty, most patients need hair removal on the donor skin area. Electrolysis or laser hair removal are provided by the NHS if deemed necessary by the surgeon. Other types of masculinising or feminising genital surgery do not typically require hair removal.

Facial surgery

Some TGD people feel that facial reconstruction is necessary to be perceived as female and be safe in public places.²³ Facial feminisation surgery encompasses several craniofacial reconstructive techniques which aim to align a person’s facial anatomy more closely with their gender identity. Examples include frontal bone reduction to minimise the prominence of the supraorbital ridge, hairline advancement, rhinoplasty, mandibular angle reduction, and sliding genioplasty.^24,25

Facial feminisation surgery is currently not routinely performed by the NHS. There are several private providers, but this often requires patients to travel overseas, making facial surgery expensive and inaccessible to many people.

Vocal surgery

Some TGD people feel that aligning their voice with their gender identity is essential to be perceived correctly and feel safe in public places.¹¹ Gender affirming voice and communication therapy is provided by the NHS to help TGD people change the pitch and timbre of their spoken voice without surgical intervention (see the ‘additional support’ section above); however, this is not always successful.²¹

Feminising GAHT does not reduce vocal cord size, meaning vocal feminisation surgery is currently the only permanent solution for feminine-identifying TGD people who have developed a deeper masculine voice.

Vocal feminisation surgery aims to raise a person’s vocal pitch into a typical female range by decreasing the vibrating mass and/or length of their vocal cords. Vocal feminisation surgery is currently not routinely provided by the NHS. There are several private providers, but these are expensive and inaccessible to many people.

Vocal masculinisation surgery is typically not required for patients receiving masculinising GAHT, as testosterone causes increased vocal cord size, resulting in a lower vocal pitch.

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Gender diverse individuals

‘Gender diverse’ and ‘non-binary’ are umbrella terms that encompass a wide variety of gender identities that cannot be described as wholly masculine or wholly feminine.

To understand non-binary identities, it is helpful to conceptualise gender as a non-linear spectrum. This includes people who feel they have no gender (e.g. agender), have a neutral gender identity (e.g. neutrois), or have a gender that fluctuates over time (e.g. gender fluid). Gender diverse people may use binary gendered pronouns, gender neutral pronouns such as they/them, neopronouns such as ze/zir, or a combination of pronouns such as she/him.

Some gender diverse people may choose to access gender affirming healthcare to alleviate gender dysphoria and/or increase gender euphoria by aligning their body more closely with their gender identity. All TGD people can access any combination of the treatments described in this article.

The World Professional Association of Transgender Healthcare (WPATH) recommends that clinicians work with gender diverse non-binary people to develop an individualised treatment plan which addresses their specific concerns.

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Key points

• Gender Incongruence describes a ‘marked and persistent incongruence between an individual´s experienced gender and their assigned sex’.
• Dysphoria and/or euphoria may arise as symptoms of gender incongruence.
• If a patient tells you they are transgender or gender diverse (TGD), they should be referred to a gender dysphoria clinic (GDC) without any delay.
• Numerous studies have demonstrated that gender affirming treatments are safe and effective ways to reduce mental health symptomology and improve quality of life for TGD people.^4,5,11,13,16
• All TGD people can access any combination of the treatments described in this article.
• Gender affirming hormone treatment (GAHT) involves prescribing an exogenous sex hormone to promote the development of secondary sex characteristics which align with the person’s gender identity.
• If a patient does not experience sufficient suppression of their endogenous sex hormone then a GnRHa ‘hormone blocker’ medication should be added to their regimen.
• There are several surgeries available to help TGD people, including genital reconstructive surgery, chest surgery, facial surgery and vocal surgery.

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Reviewer

Dr Michael Brady

National Advisor for LGBT Health, NHS England

Sexual Health and HIV Consultant, Kings College Hospital

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Editor

Dr Chris Jefferies

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References

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2. World Health Organization. HA60 Gender incongruence of adolescence or adulthood. International statistical classification of diseases and related health problems.
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13. Rasmussen, S. M. et al. Eating disorder symptomatology among transgender individuals: a systematic review and meta-analysis. J Eat Disord 11, 84 (2023).
14. Nobili, A., Glazebrook, C. & Arcelus, J. Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis. Rev Endocr Metab Disord 19, 199–220 (2018).
15. Bannister, J. J. et al. Sex Differences in Adult Facial Three-Dimensional Morphology: Application to Gender-Affirming Facial Surgery. Facial Plastic Surgery & Aesthetic Medicine 24, S-24-S-30 (2022).
16. Hembree, W. C. et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism 102, 3869–3903 (2017).
17. Bayar, E. et al. Fertility preservation and realignment in transgender women. Human Fertility 1–20 (2023) doi:10.1080/14647273.2022.2163195.
18. Gamete (egg, sperm) and embryo storage limits: response to consultation. GOV.UK. Available from: [LINK]
19. Adoption and gender re-assignment processes – Primary Care Support England. Available from: [LINK]
20. Simpson, A. P. Phonetic differences between male and female speech: Phonetic differences between male and female speech. Language and Linguistics Compass 3, 621–640 (2009).
21. Quinn, S., Oates, J. & Dacakis, G. The Effectiveness of Gender Affirming Voice Training for Transfeminine Clients: A Comparison of Traditional Versus Intensive Delivery Schedules. Journal of Voice S0892199722000674 (2022) doi:10.1016/j.jvoice.2022.03.001.
22. Gender dysphoria – Treatment. nhs.uk. Available from: [LINK]
23. Morrison, S. D. et al. Prospective Quality-of-Life Outcomes after Facial Feminization Surgery: An International Multicenter Study. Plastic and Reconstructive Surgery 145, 1499–1509 (2020).
24. Dang, B. N. et al. Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose. Arch Plast Surg 48, 503–510 (2021).
25. Dang, B. N. et al. Evaluation and treatment of facial feminization surgery: part II. lips, midface, mandible, chin, and laryngeal prominence. Arch Plast Surg 49, 5–11 (2022).

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