Abstract
Background
Research on motivations and impact of gynaecological gender-affirming surgeries (GGS)—such as hysterectomy and oophorectomy—on transmasculine and gender diverse individuals remains limited.
Aim
This study aimed to evaluate patient-reported outcomes of GGS, focusing on motivations and the surgeries’ effects on dysphoria and quality of life.
Methods
A prospective cohort study was conducted in which transmasculine and gender diverse individuals undergoing GGS were included between August 2022 and February 2024. Preoperative and postoperative (3 and 9 months) data were collected through online questionnaires, including self-constructed and validated measures (Gender Congruence and Life Satisfaction Scale and Short Form-12 Health Survey). Self-constructed measures were used to collect data on general health, motivation for surgery, recovery, and the impact of surgery on various domains (i.e. dysphoria, mental well-being, self-esteem, sexual well-being and overall impact) measured on an 11-point Likert scale (−5 to +5), corresponding with very negative to very positive. A sample size calculation resulted in a sample of 109 participants.
Results
The study included 112 participants; 69 (60.7%) underwent hysterectomy, 6 (5.4%) salpingectomy, 32 (28.6%) colpectomy with hysterectomy, and 6 (5.4%) colpectomy alone. Gender dysphoria (95.0%) was the primary motivator. Other motivations included physical complaints (67.0%) and pregnancy prevention (55%) for hysterectomy. For colpectomy, reasons included penetration avoidance (75.8%) and future surgery preparation (97%). Surgery resulted in significant improvement across all domains, with a median of +3 (IQR 1–5) for dysphoria and +3 (IQR 2–5) for overall impact. The majority reported positive effects postoperative, although a small minority experienced no change or a negative impact in various domains.
Discussion
Gynaecological gender-affirming surgeries can significantly reduce dysphoria and positively impact transmasculine and gender diverse individuals. At the same time, this study highlights the diversity of experiences, showing that while these procedures have affirming potential, the process of postoperative recovery can be complex and varied.
Keywords: Gynaecological gender-affirming surgeries, hysterectomy, motivation, patient-reported outcomes, transmasculine individuals
Introduction
Over the past decade, the number of transmasculine and gender-diverse individuals seeking medical gender-affirming care has increased significantly (Arcelus et al., 2015; Wiepjes et al., 2018). These treatments, which include hormonal therapy and various surgical procedures, can play an essential role in alleviating gender dysphoria and improving quality of life (Coleman et al., 2022; Nobili et al., 2018). Among the gender-affirming surgeries available are several gynaecological surgeries, including hysterectomy, oophorectomy, salpingectomy, and/or colpectomy (Vestering et al., 2025). These procedures entail the surgical removal of the uterus, ovaries, fallopian tubes, and vaginal epithelium, respectively. The colpectomy stands out as a more complex and higher-risk procedure (Nikkels et al., 2024). Furthermore, as the colpectomy reduces the risk of severe complications in subsequent penile reconstruction surgeries with urethral lengthening, it is a prerequisite for such procedures at multiple centers (Al-Tamimi et al., 2018; Nikkels et al., 2024).
In the context of an individualized and non-pathologising approach to gender-affirming care, including the patient’s perspective measured by patient-reported outcomes (PROs) has become essential in assessing the outcomes of medical interventions (Kaur et al., 2024; Klassen et al., 2018). PROs provide a valuable patient-centred perspective on motivations, subjective experiences, and quality of life improvements, and are sensitive to population-specific treatment goals.
Gynaecological surgeries are far more common among transmasculine and gender diverse individuals than genital surgeries, with approximately 41% opting for a hysterectomy, whereas only 7% undergo genital surgery (Elfering, 2023). However, gynaecological gender-affirming surgeries (GGS) remain underrepresented in research in transmasculine and gender diverse individuals, with most studies to date focusing on outcomes of external genital surgeries. Furthermore, studies that have focussed on GGS are mainly limited to surgical outcomes (Bretschneider et al., 2018; Gold et al., 2021), leaving broader implications for patient mental health, satisfaction, and overall well-being unaddressed (Bretschneider et al., 2018; Chen et al., 2020). Significantly, in the Netherlands, the removal of the Transgender Health Act in 2014 marked a pivotal shift in the gynaecological gender-affirming care landscape. Thereafter, transgender individuals were permitted to change their gender on official documents without undergoing surgical removal of their reproductive organs. This reform has allowed individuals to make gender-affirming surgical choices based on personal preferences rather than dictated by legal requirements. At our center, this shift has led to a decline in individuals opting for hysterectomy (with or without oophorectomy) during the first four years of treatment, from 80% before 2014 to 19% in 2021 (see Figure 1) (Amsterdam UMC, 2025; Wiepjes et al., 2018). Additionally, we have seen an increase of requests for salpingectomy, instead of a complete hysterectomy, aimed at reducing dysphoria associated with the potential of becoming pregnant.
Figure 1.
Number of individuals opting for hysterectomy and bilateral salpingo-oophorectomy after the start of GAHT.
This evolving landscape highlights the need to further improve our understanding of the motivations for and patient-reported outcomes of GGS. Therefore, in this prospective cohort study, we evaluated patient-reported outcomes of GGS, focusing on motivation and the experienced impact of these surgeries on dysphoria and quality of life.
Materials and methods
Participants
For this single-center prospective cohort study, transmasculine and gender-diverse individuals undergoing GGS—including salpingectomy, hysterectomy, oophorectomy, colpectomy, or a combination of these procedures—were included. Inclusion criteria were a self-identified transmasculine or gender-diverse gender identity (i.e. assigned female at birth), eligibility for GGS as per Dutch gender-affirming care guidelines, minimum age of eighteen, sufficient knowledge of the Dutch language, and ability to provide informed consent.
Setting
The study was conducted at the Amsterdam University Medical Center (UMC). The Amsterdam UMC is a tertiary care facility and one of three academic centers in the Netherlands providing gender-affirming care. It is the only Dutch center where the robotic-assisted colpectomy procedure is performed. Dutch gender-affirming care guidelines largely adhere to the Standards of Care 8 (SOC8) of the World Professional Association for Transgender Health (WPATH). Notably, in the Netherlands, most gender-affirming treatments, including GGS and fertility preservation procedures, are covered by public health insurance and require preoperative mental health counseling and confirmation of a Gender Dysphoria diagnosis.
Supplementary Material
Funding Statement
The author(s) reported there is no funding associated with the work featured in this article.
Ethical approval
The study protocol (2020.332) was approved by the Medical Ethics Review Committee of the Amsterdam UMC on August 8, 2020. All participants provided oral and written informed consent prior to inclusion in the study.
Data collection
Between August 2022 and February 2024, participants were recruited during outpatient counseling consultations or when they were scheduled for GGS. Data were collected via online questionnaires administered preoperatively, at three and nine months postoperative. One participant underwent two surgeries within the study period and received two baseline and two three-month postoperative questionnaires. Medical data, including perioperative complications, were retrieved from medical files in addition to the questionnaires. Complications were reported following the Clavien-Dindo (CD) Classification (Dindo et al., 2004).
Outcome measures that are tailored to a specific surgery and focus on its most relevant outcomes are likely to be more sensitive to treatment effects than generic outcome measures. However, no validated outcome measure specified for GGS exists. Therefore, validated outcome measures and self-constructed questionnaires were used to collect a comprehensive selection of patient-reported outcomes. All self-constructed questionnaires were rigorously tested by professionals and transmasculine and gender diverse individuals. The self-constructed questionnaires were developed based on themes identified from patient interviews (Vestering et al., 2025) and a focus group with gynecologists performing GGS, which discussed motivations and outcomes from a clinical perspective. Transcripts from the interviews and the focus group were analyzed using thematic analysis to identify relevant outcome domains. The questionnaires were constructed by a multidisciplinary team, including gynecologists, psychologists, and researchers experienced in developing patient-reported outcome measures. Draft questionnaires were developed based on these domains, combined with validated outcome measures and evaluated by cognitive interviews with four individuals who had undergone GGS (Balza et al., 2022). These individuals completed the questionnaires and provided feedback on their content and clarity. Revisions were made based on their input to finalize the questionnaires used in this study. Figure 2. displays an overview of which measures were included in the questionnaires at each time point. A translated version of the questionnaires are included in the supplementary materials.
Figure 2.
Questionnaires at baseline, 3 months and 9 months postoperative.
General health data: a self-constructed questionnaire was used to collect self-reported general health data (e.g., body mass index (BMI), history of smoking, medical history (e.g., gender-affirming care, prior surgeries), gynaecological complaints (e.g., bleeding, abdominal or pelvic pain or discharge), and gestational history.
Motivation for Surgery: a self-constructed questionnaire evaluated varying motivations to opt for a specific surgery, which could be selected from a drop-down list. Varying domains were included, and the question was followed by an open-ended question regarding participants’ expected outcomes in these domains: dysphoria, physical complaints (now or fear of), sexuality, and pregnancy.
Recovery & physical complaints: a self-constructed self-report questionnaire was used to collect data on the duration of recovery (defined as the time to resume daily activities) and remaining physical complaints (e.g., pain, bleeding, and fluid loss).
Impact of surgery: a self-constructed questionnaire, retrospectively evaluated the impact of the surgery on five different domains (dysphoria, mental well-being, self-esteem, sexual well-being and overall well-being). An 11-point bipolar Likert scale was used to evaluate the extent to which the surgery had very negatively (-5) to very positively (+5) influenced a participant on a specific domain at the moment of completion. No impact was indicated by 0. Each scale was followed by an open-ended question asking the participant to elaborate on why and how the surgery had influenced them in that domain. Although the study was prospective and included repeated measures for some validated instruments, we chose to measure the impact of surgery in these five domains using retrospective self-evaluation rather than pre- and post-surgery comparisons. This approach allowed participants to directly reflect on the perceived change since surgery—providing a more subjective, meaningful evaluation of personal outcomes. It also addressed the lack of validated, sensitive tools specific to these domains in the context of GGS. For this reason it was decided to opt for a a self-constructed questionnaire in addition to validated questionnaires. The domains for GGS were chosen as most relevant based on previous qualitative research (Vestering et al., 2025).
Gender Congruence and Life Satisfaction Scale (GCLS)(Jones et al., 2019): this self-report measure evaluates gender (in)congruence, related mental well-being, and life satisfaction in relation to gender-affirming medical interventions. In the current study, we used the subscales of gender-related mental well-being and satisfaction with life, which included 21 of the 38 questions of the GCLS. Statements are scored on a 5-point scale (always (1); never (5); or vice versa). A higher mean score indicates a more positive outcome, reflecting better gender-related mental well-being and life satisfaction.
Short Form-12 Health Survey(SF12)(Ware et al., 1996): this widely used standardized outcome measure assesses the physical and mental-health -related quality of life over the preceding four weeks, based on 12 items. Scores for both domains range from 0 to 100, with higher scores indicating more optimal quality of life. Dutch reference data (with a population mean score of approximately 50) were used to calculate the Physical Component Summary (PCS) and the Mental Component Summary (MCS)(Mols et al., 2009).
Sample size
A sample size calculation was conducted to determine the minimum required sample size using a two-tailed test with the null hypothesis assuming no impact of surgery. The calculation was based on the expected change in the "impact of surgery” on domain “dysphoria" (response scale: −5 to +5). This outcome was selected as it assesses the perceived impact of the surgery and is particularly sensitive to changes in dysphoria. The preoperative score was assumed to be 0, as no impact of the surgery was present preoperatively. Given the expected heterogeneity in motivations for surgery and different types of surgery within the cohort, we estimated a relatively high standard deviation of 5. A mean difference of 2 (corresponding with a moderate impact of the surgery) was considered clinically relevant and used as the expected effect size. The sample size was calculated based on a 95% confidence level and 90% statistical power. We increased the required sample size by 15% to account for potential non-normal distribution (Lehmann & D’Abrera, 1998). After adjusting for a lost-to-follow up of 30%, a minimum sample size of 109 participants was obtained.
Statistical analysis
Cohort characteristics and questionnaire responses are reported as mean ± standard deviation, median (interquartile range), or as frequencies and percentages, depending on the data type. To evaluate differences between respondents and non-respondents in baseline characteristics (age, BMI, smoking, type of surgery, postoperative complications, and sexual activity) and questionnaire scores at baseline (SF12 and GCLS) were calculated using Chi-square or Mann-Whitney U test, depending on the data type.
To evaluate changes in the “impact of surgery scores” (self-constructed measure) compared to the baseline value of 0 (H0: no impact of surgery), a Wilcoxon signed-rank test was used. Differences in the “impact of surgery scores” between 3- and 9 months postoperative were calculated using the Wilcoxon matched-pair signed rank test. These analyses were performed both for the entire cohort and in subanalyses by surgery type. To explore potential differences in “impact of surgery” scores between participants with and without postoperative complications, a Mann-Whitney U test was applied. Comparisons in SF12 and GCLS scores pre- and postoperative were calculated using paired t-tests. Depending on the type of test, effect sizes were calculated, including Cohen’s d; to estimate the effect size of the Wilcoxon matched-pair signed-rank test, Cohen’s d was approximated by dividing test statistic by the number of observations. Statistical analyses were performed using SPSS Statistics, version 22.0 (IBM, Armonk, NY). Qualitative quotes from the open-ended questions were sorted per domain, after which quotes that represented the variability of the outcomes were selected.
Results
Cohort characteristics and surgical outcomes
In total, 112 transmasculine individuals were included in the cohort, of which 69 (60.7%) underwent a hysterectomy, 6 (5.4%) salpingectomy, 32 (28.6%) robotic-assisted laparoscopic colpectomy (RaLC) combined with hysterectomy, 5 (4.5%) robotic-assisted laparoscopic colpectomy and one vaginal colpectomy. Nearly half of the participants opted for a combined oophorectomy during their surgery. One participant underwent a salpingectomy and hysterectomy separately within the duration of the study period.
The response rate at baseline was 89.4%, 70.5% (n = 79) at three months and 67.3% (n = 76) at nine months postoperative. Table 1 displays Cohort characteristics, including postoperative complications as classified by the Clavien Dindo classification (CD). No statistically significant differences in baseline characteristics or questionnaires (SF12 and GCLS) were found between respondents and non-respondents. The mean age of participants was 25.5 years SD ± 6.0. The majority of participants identified as male (n = 92 (92%), 8 participants identified as non-binary (8%)). Most participants were on testosterone treatment (92.9%) at the time of the surgery and had undergone a gender-affirming mastectomy (94.6%). No intra-operative complications were reported. Post-hysterectomy complication rate was 13%, with 8.7% experiencing low-grade postoperative complications (CD 1 + 2, e.g. wound infection, urinary tract infection, or hemorrhage with no reintervention) and 4.3% high-grade complications requiring re-surgery (CD >3a, e.g. hemorrhage or cuff dehiscence). In 36.9% of participants undergoing a colpectomy, a low-grade postoperative complication was reported, while in 5.3%, a high-grade complication was reported.
Table 1.
Baseline characteristics.
| Variables | N = 112 | |||
|---|---|---|---|---|
| Age mean ± standard deviation | 25.5 | ± 6.0 | ||
| Gender identityα, n(%) | Male | 92 | (92.0%) | |
| Non-binary | 8 | (8.0%) | ||
| Testosterone treatment, n(%) | Yes | 104 | (92.9%) | |
| No | 8 | (7.1%) | ||
| Other hormonal treatmentβ, n(%) | Progesterone | 4 | (3.6%) | |
| GnRH-agonist | 3 | (2.4%) | ||
| Previous gender-affirming surgeries, n(%) | Mastectomy | 106 | (94.6%) | |
| Hysterectomy | 6 | (5.4%) | ||
| Phalloplasty | 1 | (0.94%) | ||
| Sexually active pre-surgery¥, n(%) | 75 | (77.3%) | ||
| Smokingβ, n(%) | Active smoker | 15 | (14.7%) | |
| Previous smoker | 31 | (30.4%) | ||
| Non smoker | 56 | (54.9%) | ||
| Type of current surgery, n(%) | Hysterectomy | 69Ω | (61.6%) | |
| Salpingectomy | 6 | (5.4%) | ||
| RaLC* with hysterectomy | 32 | (28.6%) | ||
| RaLC | 5 | (4.5%) | ||
| Vaginal colpectomy | 1 | (0.9%) | ||
| Concomitant oophorectomy, n(%) | 55 | (49.1%) | ||
| Postoperative complications, n(%) | Hysterectomy | CD 1 + 2 | 6 | (8.7%) |
| CD >3a | 3 | (4.3%) | ||
| Colpectomy** | CD 1 + 2 | 14 | (36.9%) | |
| CD >3a | 2 | (5.3%) | ||
RaLC = Robotic assisted colpectomy
RaLC with or without hysterectomy / vaginal colpectomy
12 missing.
11 missing.
16 missing.
1 participant underwent a salpingectomy and hysterectomy separately.
The mean duration of recovery, defined as the self-reported number of weeks until the ability to resume daily activities, was 5.5 ± 2.6 weeks, and the majority (88.6%) of participants stated they had been able to resume their daily activities (e.g. work, studies) three months postoperative. However, about 40% still experienced physical complaints at three months (decreasing to 24% at nine months), most frequently bleeding, discharge, pain at the surgical site, and difficulty urinating (see Table 2). Vasomotor symptoms (i.e. hot flashes and increased sweating) were reported by 15% of the participants who underwent oophorectomy.
Table 2.
Postoperative physical complaints.
| Self-reported physical complaints 3 and 9 months postoperatively | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Symptoms | Type of surgery |
||||||||
| Colpectomy n = 24Ω |
Hysterectomy n = 50α |
Salpingectomy n = 5β |
BSO yes N = 38¥ |
||||||
| 3 months | 9 months | 3 months | 9 months | 3 months | 9 months | 3 months | 9 months | ||
| No physical complaints | 15(62.5%) | 16 (72.7%) | 30 (60.0%) | 37 (77.1%) | 2 (40.0%) | 2 (66.7%) | |||
| Bleeding | 5 (20.8%) | 0 | 8 (16.0) | 1 (2.0%) | – | – | |||
| Discharge | 4 (16.7%) | 1 (4.2%) | 4 (8.0%) | 2 (3.9%) | 1 (20.0%) | – | |||
| Odor | 2 (8.3%) | 2 (8.3%) | 1 (2.0%) | 1 (2.0%) | – | – | |||
| Abdominal pain | 1 (4.2%) | 0 | 10 (20.0%) | 5 (9.8%) | 3 (60.0%) | 1 (25%) | |||
| Urinary problems | 3 (12.5%) | 3 (12.5%) | 4 (8.0%) | 3 (6.3%) | – | 1 (25%) | |||
| Pain colpectomy wound (resting) | 3 (12.5%) | 0 | |||||||
| Pain colpectomy wound | 3 (12.5%) | 1 (4.2%) | |||||||
| Trouble sitting | 4 (16.7%) | 0 | |||||||
| Vasomotor symptoms* | 7 (18.4) | 6 (15%) | |||||||
Missings: 3 months/9 months.
14 / 14.
19 /18.
1 / 2.
17 / 15 missing.
Hot flashes, increased sweating.
Motivation for surgery
Table 3 displays an overview of the varying motivations for different surgeries. Dysphoria was a motivating factor for the vast majority (95.0%) across all surgeries. The hysterectomy was in 67% also motivated by physical complaints such as bleeding (37.7%), abdominal pain (52.5%) and discharge (16.4%). Prevention of pregnancy was an important motivator for participants opting for either a hysterectomy or a salpingectomy. In contrast, the most frequently reported motivations for the colpectomy were preventing penetration during sexual intercourse and preparation for future external genital surgeries. Most participants who opted for oophorectomy did so to eliminate feminine hormones (87.8%), while those who kept their ovaries primarily cited having a backup for sex steroids in the event access to exogenous testosterone is impaired (71.2%) or potential future fertility considerations (25.0%).
Table 3.
Motivations for various gynaecological gender-affirming surgeries.
| Motivations for various surgeries | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| N | Dysphoria | Preparatory to other surgeries | Physical complaints | Preventing pregnancy | Fear of complaints | Future problems | No penetration | No Discharge when aroused | |
| All surgeries | 100α | 95 (95.0%) | 47 (47.0%) | 52 (52.0%) | 27 (27.3%) | 39 (39.4%) | 47(47.0%) | – | – |
| Hysterectomy | 61β | 56 (91.8%) | 15 (23.1%) | 41 (67.2%) | 31 (45.6%) | 28 (45.9)%) | 32 (52.5%) | – | – |
| Colpectomy | 33Ω | 33 (100%) | 32 (97.0%) | 9 (27.3%) | 2 (6.1%) | 8 (24.2%) | 15 (45.5%) | 25 (75.8%) | 6 (18.2) |
| Salpingectomy | 6 | 6 (100%) | – | – | 6 (100%) | 1 (16.6%) | – | – | – |
Impact of surgery
Table 4 displays the median scores of the impact of surgery scales on dysphoria, mental well-being, confidence, sexual well-being and an overall impact on well-being scores at three and nine months postoperative. Participants reported on average significant improvements compared to baseline across all domains, with the highest scores for dysphoria and mental well-being. No significant changes were found between the two time-points.
Table 4.
Impact of surgery scores at three and nine months.
| 3 Months versus baseline = 0 |
9 Months versus baseline = 0 |
3 Versus 9 months | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| All procedures | Median (IQR)*
n = 791 |
p-Valueα | Effect sizeβ | Effect n (%) |
Median (IQR) n = 762 |
p-Valueα | Effect sizeβ | Effect n (%) |
p-ValueΩ
n = 623 |
||||
| + | 0 | − | + | 0 | − | ||||||||
| Dysphoria | 3 (1–4) | <0.001 | 0.67 | 61 (77.2%) | 12 (15.2%) | 6 (7.6%) | 3 (1–5) | <0.001 | 0.77 | 63 (81.8%) | 12 (15.6%) | 2 (2.6%) | 0.09 |
| Mentally | 2 (0–3) | <0.001 | 0.74 | 56 (70.9%) | 17 (21.5%) | 6 (7.6%) | 2 (0–4) | <0.001 | 0.74 | 57 (75.0%) | 15 (19.7%) | 4 (5.3%) | 0.81 |
| Confidence | 1 (0–3) | <0.001 | 0.68 | 52 (65.8%) | 25 (31.6%) | 2 (2.5%) | 2 (0–3) | <0.001 | 0.69 | 49 (64.5%) | 24 (31.6%) | 3 (3.9%) | 0.94 |
| Sexual experience | 0 (0–2) | <0.01 | 0.35 | 32 (40.5%) | 35 (44.3%) | 12 (15.2%) | 0 (0–1) | <0.01 | 0.32 | 25 (33%) | 39 (51.3%) | 12 (15.8%) | 0.73 |
| Overall | 3 (1–5) | <0.01 | 0.82 | 70 (88.6%) | 6 (7.6%) | 3 (3.8%) | 3 (2–5) | <0.001 | 0.81 | 64 (84.2%) | 9 (11.8%) | 3 (3.9%) | 0.40 |
| Hysterectomy | n = 50 (19 missing) | n = 49 (20 missing) | n = 43 (26 missing) | ||||||||||
| Dysphoria | 3 (1–5) | <0.001 | 0.71 | 39 (78%) | 8 (16%) | 3 (6%) | 3 (1–5) | <0.001 | 0.75 | 39 (78.0%) | 9 (18.0%) | 2 (4%) | 0.46 |
| Mentally | 3 (0–3) | <0.001 | 0.75 | 37 (74%) | 9 (18%) | 4 (8%) | 2 (0–4) | <0.001 | 0.71 | 35 (71.4%) | 10 (20.4%) | 4 (8.2%) | 0.80 |
| Confidence | 1.5 (0–3) | <0.001 | 0.74 | 36 (72%) | 13 (26%) | 1 (2%) | 2 (0–3) | <0.001 | 0.69 | 33 (67.3%) | 13 (26.5%) | 3 (6.1%) | 0.78 |
| Sexual experience | 0 (0–2) | 0.02 | 0.67 | 22 (44%) | 19 (38%) | 9 (18%) | 0 (0–1) | 0.17 | 0.20 | 15 (30.3%) | 23 (46.9%) | 11 (22.4%) | 0.84 |
| Overall | 3 (2–5) | <0.001 | 0.84 | 46 (92%) | 4 (8%) | – | 3 (2–5) | <0.001 | 0.81 | 41 (83.7%) | 5 (10.2%) | 3 (6.1%) | 0.16 |
| Colpectomy | n = 243 (14 missing) | n = 23 (15 missing) | n = 16 (22 missing) | ||||||||||
| Dysphoria | 0.01 | 0.52 | 17 (70.8%) | 4 (16.7%) | 3 (12.5%) | 2 (1–4) | <0.001 | 0.82 | 20 (87%) | 3 (13%) | – | 0.08 | |
| Mentally | <0.01 | 0.56 | 14 (58.3%) | 8 (33.3%) | 2 (8.3%) | 2 (1–4) | <0.001 | 0.78 | 18 (78.3%) | 5 (21.7%) | – | 0.52 | |
| Confidence | 0.01 | 0.52 | 12 (50%) | 11 (45.8%) | 1 (4.2%) | 2 (0–3) | <0.001 | 0.67 | 13 (56.5%) | 10 (43.5%) | – | 0.67 | |
| Sexual experience | 0.11 | 0.33 | 7 (29.2%) | 15 (62.5%) | 2 (8.3%) | 0 (0–2) | 0.04 | 0.42 | 8 (34.8%) | 14 (60.9%) | 1 (4.3%) | 0.50 | |
| Overall | <0.001 | 0.74 | 20 (83.3%) | 2 (8.3%) | 2 (8.3%) | 3 (1–4) | <0.001 | 0.80 | 19 (82.6%) | 4 (17.4%) | – | 0.57 | |
| Salpingectomy | n = 5 (1 missing) | n = 4 (2 missing) | n = 3 (3 missing) | ||||||||||
| Dysphoria | 0.04 | 0.91 | 5 (100%) | – | – | 5 (3.5–5) | 0.06 | 0.95 | 4 (100%) | – | – | 0.18 | |
| Mentally | 0.04 | 0.91 | 5 (100%) | – | – | 3.5 (2.3 − 4.8) | 0.07 | 0.91 | 4 (100%) | – | – | 0.32 | |
| Confidence | 0.07 | 0.82 | 4 (80%) | 1 (20%) | – | 3 (0.8 − 4.5) | 0.1 | 0.82 | 3 (75%) | 1 (25%) | – | 0.18 | |
| Sexual experience | 0.14 | 0.66 | 3 (60%) | 1 (20%) | 1 (20%) | 2 (0 − 4.8) | 0.18 | 0.67 | 2 (50%) | 2 (50%) | – | 0.32 | |
| Overall | 0.04 | 0.92 | 5 (100%) | – | – | 4 (2.3–5) | 0.07 | 0.92 | 4 (100%) | – | – | 0.16 | |
IQR: Interquartile range.
Comparison with baseline value of 0.
Cohen’s D.
Comparison of 3 and 9 months score.
34 missing.
37 missing.
51 missing.
At nine months postoperative, the impact on dysphoria was scored at a median of +3.0 (corresponding with a positive impact; IQR 1–5), a significant change from baseline (p < 0.001), with a moderately large, positive effect size (Cohen’s d .77). The majority of participants (81.8%) reported an improvement compared to 15.2% that reported no change, and 7.6% reporting a worsening of dysphoria.
Similar patterns were observed for mental well-being, confidence, and overall impact on well-being. 64.5–84.2% reported positive change with moderate (.69) to large (.81) effect sizes. At nine months, the indicated improvements were +2 (moderate improvement of mental well-being; (IQR 0–4)) and +3 (moderate—strong overall improvement; (IQR 1–5)), without significant differences between 3 and 9 months.
A different pattern was found for the impact on sexual well-being. For this domain, more participants reported either no impact (51.3%) or a negative impact (15.8%). The average impact score was still positive, with a + 0.7 (±SD 2.0) difference and a small effect size (.32). Again, no statistically significant differences were observed between 3 and 9 months.
Table 4 also includes the subanalyses by surgery type which revealed nuanced but consistent patterns. At nine months postoperative the median impact score for dysphoria was 3 (IQR 1–5) after hysterectomy, 2 (IQR 1–4) after colpectomy and 5 (3.5–5). For mental well-being, confidence and overall impact too the majority scored positively. However, the domain of sexual well-being showed more variability, with some participants reporting limited or negative impact. Due to small sample sizes—particularly for salpingectomy and at the nine-month follow-up for certain procedures—these subanalyses should be interpreted with caution. Subanalyses comparing groups with and without complications revealed no significant differences for most outcomes at nine months postoperative (all p > .05). However, participants with complications reported lower sexual well-being, with a statistically significant difference (p = .02) and a small to medium effect size (d = 0.58). A trend toward lower overall impact scores was also observed (p = .073), though this did not reach statistical significance.
Table 5 includes a selection of the participant quotes in response to the open-ended follow-up questions elaborating on the impact of surgery scores. The quotes demonstrate in what way surgeries had a positive impact on reducing dysphoria, anxiety, and stress related to pregnancy risk, menstruation, and bodily functions that felt misaligned, and how this led to greater confidence, mental well-being, and sexual comfort. Some experienced increased ease in intimacy and body acceptance. However, some of the respondents reported minimal change or struggled with post-surgical hormonal shifts and the physical and mental impact of the surgery on their recovery. Physical changes, such as vaginal dryness after oophorectomy or reduced orgasm after hysterectomy, were reported to have negatively impacted their sexual well-being by some participants.
Table 5.
Explanatory quotes on the impact of the surgery.
| Positive impact on dysphoria mentally well-being |
| “My dysphoria was triggered by the knowledge I could get pregnant (even a really small chance was too big of a risk), that gave me really intense anxiety. Because of this I used to avoid dating and relationships” (hysterectomy, 3 months post op, 27 y/o) |
| “Without the possibility to menstruate or become pregnant my brain is a lot calmer and I experience less stress, even more than I had expected.” (hysterectomy & oophorectomy, 9 months post-op, 22 y/o) |
| “Unexpectedly, not being fertile anymore made me feel more comfortable with vaginal penetrative sex. (…) I seem to have come to a point where I am happy with my body. I had assumed I would only get there if I had male genitals as well.” (hysterectomy, 9 months post-op, 19 y/o) |
| “Removing the vagina has decreased my dysphoria significantly, because the vagina was a big source for dysphoric feelings. I feel more comfortable and more of a man without a vagina.” (Robot colpectomy with hysterectomy & oophorectomy, nine months post-op, 23 y/o) |
| “Although nothing has changed visually I notice that I experience my genital area slightly less feminine. Which makes it easier for me to be sexually free with partners although the effect is minimal, it is already a big difference because I am so heavily dysphoric about my genital area this small improvement is already quite a liberation.” (Robot colpectomy with hysterectomy & oophorectomy, nine months post-op, 22 y/o) |
| Negative/no impact on dysphoria and/or mental well-being |
| “Not so much the surgery itself but the fact that the people around me were preoccupied with my transition again, while I wasn’t. (…) I hated that because of this I felt like ‘such a transgender’ again. That hit me harder than I had expected.” (Hysterectomy, 3 months post-op, 25 y/o) |
| “After the surgery I fell back into depression from a few years ago. The fact that my hormones were all over the place really influenced how I felt. Luckily I’m feeling a bit better already.” (Robot colpectomy combined with hysterectomy & oophorectomy, 3 months post-op, 23 y/o) |
| Positive impact sexual well-being |
| “Because I know my body has literally become less female, I feel like a can be free more easily, and be naked around partners quicker and longer. Also not getting wet, which is typically female. So I can enjoy sex mentally more easily rather than stress about dysphoria and work around that.” (Robot colpectomy combined with hysterectomy & oophorectomy, 3 months post-op, 22 y/o) |
| Negative impact on well-being |
| “Positive because I cannot get pregnant anymore. But negative because penetration has become even less comfortable (due to dryness).” (hysterectomy & oophorectomy, 9 months, 28 y/o) |
| “The orgasms are less intense, it feels different.” (hysterectomy, 9 months, 24 y/o) |
| Positive impact confidence |
| “Although the surgery didn’t change anything in my appearance, I feel more like myself without all these excess organs that really felt like betrayal of my body, and that gives me more confidence.” (Hysterectomy & oophorectomy, 9 months, 22 y/o) |
| “The fact or confirmation I don’t have a uterus anymore, something cis women have, gives me peace of mind and confidence because I’m a men.” (hysterectomy & oophorectomy, 3 months post-op, 21 y/o) |
| No impact on confidence |
| “For the outside world, nothing changes.” (Robot colpectomy combined with hysterectomy & oophorectomy, 9 months post-op, 20 y/o) |
Pre-and postoperative SF 12 and GCLS data
At baseline, participants reported SF12 within the range of normative data with slightly higher scores for physical than (PCS = 54.87 ± 5.23) for mental health (MCS = 42.64 ± 6.92). At follow-up (administered at 3 months only), no statistically significant differences were observed (PCS = 55.13 ± 5.48, Cohen’s d = 0.04; MCS = 42.54 ± 6.40, Cohen’s d = −0.02). GCLSscores showed positive well-being (mean 3.75 ± 0.46) at baseline. After surgery, scores increased slightly, resulting in a borderline statistically significant difference (administered at 9 months only: mean 3.87 ± 0.52, p = 0.06). The observed effect size (Cohen’s d = 0.23) indicates a small positive impact of GGS on gender-related well-being in addition to the existing effects of testosterone therapy and mastectomy, for which the study was insufficiently powered to confirm.
Discussion
This prospective cohort study aimed to investigate the motivations for and the patient-reported outcomes of GGS during the first 9 months after surgery compared to baseline. We found that the surgery positively impacted most participants across all domains of the “impact of surgery score,” with significant improvement compared to baseline. The biggest impact was reported on gender dysphoria, mental well-being, and confidence. However, the effect on sexual well-being was less explicit, with half of the participants experiencing no effect in this domain. Finally, although the vast majority had experienced an overall positive impact from the surgery at three and nine months postoperative, a small proportion of participants reported that the surgery had impacted them negatively.
Our study, being one of the first toexplore patient-reported outcomes of GGS, shows how GGS can have a significant impact on various domains for transmasculine and gender diverse individuals. However, they also highlight the diversity in motivations and wide range of postoperative experiences. These diverse trajectories underscore the challenges incapturing all experiences in a standardized outcome measure. Generic outcome measures, such as the SF12 and GCLS, may lack the sensitivity to have measured the impact on individual well-being and achievement of individual goals. Although we observed a slight improvement in pre- and postoperative GCLS scores, variance in improvement may be masked by a ceiling effect, considering the high baseline score, likely influenced by prior positive experiences with GAHT and mastectomy (Nieder et al., 2021). Additionally, our outcomes indicate that some participants view gynaecological surgery as a preparatory step before additional gender-affirming surgeries, while others consider it their final step in medical gender-affirmation. This variation illustrates the limitations of linear measurement models and suggest the need for more personalized tools to evaluate gender-affirming care. Instruments like theIndividual Treatment Progress Scale (ITPS), for example, which evaluates transition-related treatment progress based on a person’s self-defined treatment pathway, may better account for this heterogeneity (Nieder et al., 2021). The ITPS recognizes transition as not a linear or uniform process, acknowledging that individuals may have varying treatment wishes depending on their goals and needs (Nieder et al., 2021).
Although we did not include the ITPS in our design—primarily because it had not been validated for this specific surgical context at the time of study design and data collection—our findings suggest that its use could significantly enhance the interpretation of outcomes in future studies.
Similarly, the integration of goal attainment scaling could provide a way to assess personal expectations and their fulfillment in more granular ways (Khullar et al., 2014). This method, already applied in urologic and pelvic surgery, focuses on setting and assessing personalized treatment goals (Brubaker et al., 2011; Khullar et al., 2014; Mannion et al., 2010; Sung et al., 2016). By exploring and discussing a patient’s expectations and aspired outcomes, realistic goals can be set by the physician and patient. Subsequently, after treatment, goal achievement is assessed using scales tailored to the individual patient as they select which outcomes are important to them (Brubaker et al., 2011; Khullar et al., 2014). Given the variability in motivations and experiences observed in our study, combining goal attainment scaling and ITPS may provide an approach that captures the highly personalized impact of GGS.
Furthermore, our findings emphasize that medical transitioning is not a universally linear or positive journey (Oosthoek et al., 2024). While the majority of participants reported positive outcomes, in line with previous reports, no impact or worsening of dysphoric feelings and mental well-being was also reported (Becker, 2023; Rachlin et al., 2010). Some of these adverse outcomes were related to the challenging postoperative period and improved over time. However, for others, the surgical experience also involved tradeoffs leading to both positive and negative outcomes, particularly in relation to sexual well-being (Gieles et al., 2025; Pipkin et al., 2024; Vestering et al., 2025). For instance, the removal of the ovaries and uterus may decrease dysphoria, but subsequential vaginal dryness or persistent postoperative pain may negatively impact sexual pleasure (Rachlin et al., 2010). These nuanced outcomes around sexual well-being may also reflect the complex relationship transgender individuals may have with their sexual bodies and functioning (Pipkin et al., 2024). Increased attention to a dysphoric body region during and after surgery, even when the surgery itself is affirming, may cause (temporarily) decreased sexual desire or pleasure. Importantly, sexual well-being is shaped by a myriad of biopsychosocial factors, and is not solely determined by anatomical or hormonal changes, but also shaped by emotional, psychological, relational, and social factors (Gieles et al., 2025; Pipkin et al., 2024). This complexity is further illustrated by our subanalyses, which showed that while most outcomes did not differ significantly between participants with and without complications, those with complications reported lower sexual well-being at nine months. This finding highlights how complications may influence not only physical recovery, but also broader aspects of well-being, such as sexual functioning, and underscore the need for personalized and holistic postoperative care. Future studies are needed to further explore how GGS influence sexual pleasure and how perioperative care could be adapted to support sexual well-being more effectively.
While the overall impact was positive, we must be cautious to overly emphasize improvement as the primary indicator of success (Oosthoek et al., 2024), recognizing transitioning is a deeply personal journey with diverse care trajectories, as discussed above. Moreover, some individuals may experience setbacks before reaching a sense of alignment (Vestering et al., 2025). This complexity warrants personalized approaches allowing individuals to prioritize their desired outcomes and assess them based on their personal goals and values. This study offers a starting point to further develop such a personalized outcome measure.
For some participants, the postoperative period was challenging due to complications or symptoms such as bleeding and postoperative pain, which, in some cases, could exacerbate dysphoric feelings (Cipres et al., 2023; Vestering et al., 2025). Although the 13% complication rate post-hysterectomy aligns with other studies on laparoscopic hysterectomy in transmasculine and gender diverse individuals (Cipres et al., 2023; Gold et al., 2021), this rate is relatively high compared to reports in cisgender women that vary around 6–7% (Driessen et al., 2016). In this study, postoperative bleeding and wound infection were among the most frequently reported complications. As suggested by others, the effect of long-term testosterone on the vaginal epithelium may cause impaired healing of the vaginal cuff and could potentially increase the risk of bleeding and infections (Cipres et al., 2023; Pando et al., 2024). Similarly, this could explain the relatively high number of participants still reporting bleeding complaints three months postoperative (Cipres et al., 2023; Pando et al., 2024). Pando et al. suggest administering vaginal estrogen pre- and postoperative to promote healing and reduce the risk of bleeding (Pando et al., 2024). An additional factor that may play a role is the fact that most transmasculine and gender diverse individuals are not accustomed to experiencing vaginal bleeding, which could lead to them becoming alarmed more quickly than cisgender women (Cipres et al., 2023). As a result, transmasculine and gender diverse individuals may tend to seek medical assistance sooner and more frequently after surgery compared to cisgender women (Cipres et al., 2023). This pattern may contribute to a higher number of reported complications among transmasculine and gender diverse individuals.
Furthermore, nine months after the hysterectomy, 9.8% of participants still reported abdominal pain. In studies with cisgender women, chronic postoperative pain (>1 year) is reported in 5-30% (Brandsborg et al., 2008). Considering abdominal pain is often a motivation for surgery, chronic postoperative pain should be discussed as a risk factor of hysterectomy, as should the possibility of other causes of abdominal pain, such as irritable bowel syndrome, that will not be resolved by surgery.
Thus, our findings reinforce the importance of thorough counseling, expectation management concerning the risk of complications, bleeding, and postoperative pain, and adequate psychological guidance throughout the surgical process (Cipres et al., 2023; Vestering et al., 2025). In other gynaecological abdominal surgeries, a personalized e-health intervention, including personalized care during the postoperative period, has been shown to accelerate recovery (van der Meij et al., 2018). Combined with ITPS and goal attainment scaling, such a personalized perioperative care program could offer the support transmasculine and gender diverse individuals need on their unique journey of medical transitioning (Khullar et al., 2014; van der Meij et al., 2018).
Strengths and limitations
Although hysterectomy is far more commonly chosen among transmasculine and gender diverse individuals than genital surgery, research on its impact remains limited. This study is one of the few to specifically examine gynaecological gender-affirming surgeries and shows a significant reduction of dysphoria by these procedures alone. This is achieved by offering a relatively large sample size and a broad exploration of physical and psychological outcomes. Integrating quantitative measures, supported by qualitative follow-up questions, allowed for a nuanced understanding of participants’ experiences. Additionally, the questionnaires were specifically developed based on qualitative data from transgender patients and in close collaboration with patients and professionals, ensuring they address relevant topics for this target population.
However, some limitations should be considered when interpreting these findings. Firstly, while some validated measures were included, a non-validated questionnaire was used to assess the impact of surgery across multiple domains, as no existing transgender-specific, validated patient-reported outcome measure fully captures the complexity of gynaecological gender-affirming surgeries. Given the broader scope of our study, we prioritized a comprehensive, patient-centred approach. By combining quantitative measures with open-ended responses, we aimed to capture not only the extent of change but also the experiences underlying these shifts. However, we did not incorporate personalized outcome measures such as the ITPS or goal attainment scaling. These tools were either unavailable or insufficiently validated for this specific surgical context during the design phase. However, based on our findings, we do recognize the potential value of such measures in future research. Furthermore, future studies could benefit from incorporating other validated measures alongside qualitative methods, for instance for sexual functioning for transmasculine and gender diverse individuals to enhance comparability across studies and further explore the complexities of postoperative sexual well-being in this population. Finally, loss to follow-up may have further affected the sample’s representativeness with potentially overrepresentation of positive outcomes.
Conclusion
This study shows that gynaecological gender-affirming surgeries can have a significantly positive impact and reduce dysphoria for transmasculine and gender diverse individuals. Furthermore, it highlights the diverse experiences of transmasculine individuals undergoing gynaecological gender-affirming surgeries, demonstrating both their affirming potential and the complexities of postoperative recovery. While most participants reported positive outcomes, variations in motivations, physical recovery, and psychosocial impact emphasize the need for individualized care and personalized perioperative guidance. Gender-affirming care and gynaecological gender-affirming surgeries, in particular, warrant tailored outcome assessments, such as ITPS and goal attainment scaling, to capture their nuanced impact. This study provides a first step toward such an outcome measure for gynaecological gender-affirming surgeries, which could, alongside improved preoperative counseling and postoperative support, help optimize care practices in future.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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