A call for greater attention to embodied change in trans health research

Introduction

A large and growing body of literature has sought to understand the connection between gender-affirming medical care (GAC) and outcomes such as mental health, well-being, and overall quality of life (for recent reviews see Baker et al., 2021; Doyle et al., 2023; Shelemy et al., 2025; van Leerdam et al., 2023; What We Know, 2018). Although this literature often frames mental health as a direct outcome of GAC, there is a broad understanding in the field of trans health that the primary intent of GAC is to align an individual’s physical appearance with their experienced or desired gender. This is reflected in the most recent World Professional Association for Transgender Health (WPATH) Standards of Care, which indicates that adults may request GAC “to better align their body with their gender identity” and that adolescent care should “enable the individual’s body to align as much as required, and to the extent possible, with the person’s experienced gender” (Coleman et al., 2022, p. S31, S59). Similar statements can be found throughout the trans health literature. For example, a recent review stated that “by better aligning an individual’s physical appearance with their gender identity, GAHT [gender-affirming hormone therapy] aims to reduce body and gender dysphoria, subsequently improving psychological well-being and quality of life” (van Leerdam et al., 2023, p. 6).

Studies that draw a direct connection between GAC and mental health rest on the assumption that this alignment has been achieved, often without verifying that this is true. To narrow the distance between overall mental health and GAC, some researchers have instead framed gender dysphoria, gender congruence, or similar constructs such as gendered self-image as direct outcomes of GAC (e.g. Ashley, 2022; Davis & St. Amand, 2014; English et al., 2025). I argue that these measures are still too abstract in comparison to the concrete intended effect of GAC: a physical change to the body. My aim is to illustrate a few ways to integrate our understanding of GAC’s role in changing the physical body into research that assesses the well-being of those who access this type of medical care. I hope that doing so will bring greater clarity and insight to our understanding of the associations between GAC, gendered embodiment, and psychological well-being.

Before proceeding, I will add some necessary caveats. Although I have implied that individuals seeking GAC primarily do so due to a desire to align one’s body with their experienced gender, the reasons that people pursue GAC are varied and complex. For example, under laws that require medical transition in order to attain legal gender recognition, people may choose to have surgery primarily as a means to this end (e.g. see Yaël’s account in Sansfaçon et al., 2023). Similarly, there are a variety of decisions that people make about their bodies and appearance that may be informed by social context and personal safety as well as by their true desired embodiment (Anderson et al., 2025). These examples do not necessarily fall outside of the scope of this piece, however, because truly understanding the effects of GAC in these contexts requires us to ask the individual, “Did the medical care that you received do what you wanted it to do?” The core argument of this piece is that more researchers should be asking participants this question.

An element of GAC that does fall outside the realm of embodied change, but can certainly influence mental health, is the process of accessing, scheduling, being denied, or initiating GAC. The multilayered gatekeeping processes that affect the lives of trans people, especially their access to healthcare, have been critiqued as dehumanizing (Ashley, 2019), and qualitative data from both patients and clinicians attest to the presence of this dynamic in clinical settings (e.g. Gerritse et al., 2022; MacKinnon et al., 2020). The act of overcoming these barriers alone may be influential for one’s well-being.

There are seemingly endless ways to complicate the relationship between GAC and mental health, and my goal with this piece is to highlight one key entry point into more closely attending to the embodied psychosocial experience of receiving GAC, in hopes that others will continue to map out additional routes.

The primary outcomes of gender-affirming medical care are physiological

With these caveats in place, we know that many people start hormones and undergo surgery because they desire immediate or eventual changes to their bodies. If we limit our focus to the process in which a person undergoes GAC because they want to experience a change to their gendered body, it follows that before GAC can affect an individual’s psychological well-being, it will first affect the physical features of their body.

To illustrate this, consider the example of an individual who seeks vaginoplasty as part of their gender transition. In this example, the primary purpose of the vaginoplasty is not to allow the individual to feel more actualized in their gender, nor is it to lessen their depression. These may both be among this person’s reasons for seeking a vaginoplasty, but at the most basic level, a vaginoplasty is successful if it creates a vulva and vagina that meet the patient’s reasonable and realistic expectations of this procedure outcome. Any theorized secondary outcomes of this surgery, such as improved self-esteem or improved sexual satisfaction, should only be expected if the individual received the care and outcome that they expected. If they did not, then this individual would be unlikely to experience secondary benefits of the surgery to their gendered self-image or quality of life. It may be helpful to conceptualize this as a mediation process, where the mechanism that links a surgical intervention to mental health is the individual’s assessment of their procedure outcome.

It is reasonable to assume that someone who has received gender-affirming surgery has experienced a noteworthy change to their body. This assumption, however, should not necessarily be made in the case of hormone therapy, because any changes to the body occur much more gradually. Many studies that aim to connect hormone therapy and mental health have a relatively short follow-up time, often one year or less, and reviews that integrate these data include studies that span a variety of treatment lengths (e.g. Baker et al., 2021; Doyle et al., 2023; Shelemy et al., 2025; van Leerdam et al., 2023). Short follow-up timelines call into question whether and to what extent participants have experienced physical changes from hormone therapy during the course of the study. For example, facial hair growth resulting from exogenous testosterone develops over the course of many years (Irwig, 2017; Patel et al., 2021). If a research participant is taking testosterone in hopes of growing a substantial amount of facial hair, then to assess the association between hormone therapy and psychological well-being, a researcher must first establish that the participant has experienced the physical changes that they wanted and expected.

Possible pathways linking GAC and mental health

By reflecting on the ways that hormones and surgeries function in individuals’ lives, I aim to describe two processes that may connect GAC to mental health: an intrapersonal pathway, and an interpersonal pathway. The intrapersonal pathway is the process described above in the context of vaginoplasty. In this pathway, the individual must first experience changes to their body, and then they must be reasonably satisfied with these changes. Following these steps, the individual may experience a change to their mental health as a result of the GAC.

The interpersonal pathway is likely to be more complex than the intrapersonal pathway, because social experiences are often quite complex. If an individual takes hormones in part because they want others to perceive their gender differently, a successful outcome requires them to experience a change to their metaperceived gender, defined as the “gender one knows others perceive or treat them as, including perception as gender minority” (Bauer, 2023, p. 124). Similar to the intrapersonal pathway, the individual must then be satisfied with this change to their metaperceived gender. Once it has been established that the individual has experienced changes to their physical body and metaperceived gender, and that they are satisfied with these changes, we can expect that the individual may also experience an improvement to their overall sense of well-being.

One caveat to the interpersonal pathway is that, as many people who have transitioned genders or have otherwise been distinctly gender non-conforming can attest, one’s own metaperceived gender may be constantly shifting and difficult to pin down (this is explored at length by Serano, 2022; see also Pulice-Farrow, 2024; Brumbaugh-Johnson & Hull, 2019). How a person perceives others to be perceiving their gender can depend on many factors, including the context in which an interaction takes place, the way that the individual is presenting their gender, and others’ responses to that presentation.

My aim is not to pretend that the pathways I describe above are at all exhaustive. As mentioned earlier, the experience of starting hormones and other steps in moving toward changes to embodiment may themselves be beneficial for mental health. (That said, the interventions sometimes do not work out as planned, and they sometimes do not happen at all, both of which may also affect one’s well-being.) The process through which steps forward may influence mental health, whether because they are opportunities to exercise autonomy over one’s body, or because they represent a hope for future embodied change, or something else entirely, is also a worthy avenue for continued research.

My aim is also not to overcomplicate the research into people’s experiences of receiving GAC. Rather, my point is to highlight how important the direct effect of this care on the body is for many of the pathways that may link GAC to mental health outcomes. In doing so, I highlight several assumptions that are made when gender-affirming hormone therapy is hypothesized to improve mental health. A few of these assumptions are that 1) the person is experiencing noteworthy changes to their body, 2) they are satisfied with the direction and extent of these changes, 3) they perceive that others are perceiving their gender differently, and 4) they are satisfied with how they perceive that others are perceiving their gender. These assumptions are not always correct, and the lack of attention to them glosses over important components of the intrapersonal and interpersonal experiences that often accompany gender-affirming hormone therapy.

Application in future research

A necessary next step in this area of research is to more thoroughly investigate how individuals experience, respond to, and adapt to the physical and social outcomes of GAC. In the context of gender-affirming surgery, it is ideal to measure an individual’s experience of the changes to specific parts of their body affected by the procedure. For example, many existing studies of gender-affirming surgery conducted by surgical teams assess patient satisfaction with key outcomes of the surgery, such as location of scars following mastectomy (Shue et al., 2024), vaginal depth following vaginoplasty (Massie et al., 2018), and whether patients like the appearance of their face following facial feminization surgery (Ainsworth & Spiegel, 2010). Additionally, surgical research has highlighted the need to account for whole-body effects of gender-affirming surgery that aren’t necessarily related to the primary outcome, such as donor site morbidity following radial forearm phalloplasty (Ferrin et al., 2024). Finally, it cannot be assumed that all individuals hold different surgical outcomes at the same level of importance. An individual may be dissatisfied with an outcome (e.g. scar placement) that is not especially important to them, and highly satisfied with another aspect of their surgical outcome (e.g. appearance of the body in clothing) that is their primary reason for having surgery. Ideally, measures of satisfaction will account for diversity in transition goals and subjective definitions of success (see also Castle et al., 2025).

For hormone therapy, the whole-body effects of this intervention may make measures of overall body satisfaction more appropriate. That said, measuring specific desired outcomes of hormone therapy can still be helpful and perhaps preferable depending on the specific research question. In some existing datasets, the only available measure is a more abstract or generalized measure of an individual’s gendered experience in their body, such as gender dysphoria or gender congruence. When interpreting any findings that use these measures to infer satisfaction with one’s body, it is important to account for the ways in which these measures collapse many aspects of the personal, interpersonal, and embodied experience of gender into a single construct.

These various measures of satisfaction with physical changes should be conceptualized as mediating variables in studies that assess the relation between GAC and mental health. This does not, however, mean that researchers must conduct mediation analyses using their data. Although the variables discussed here are conceptually time-ordered (Tate, 2015), there are numerous other considerations for determining whether a mediation analysis is appropriate for a specific research question or dataset, and a full discussion of these issues is beyond the scope of this piece (see Bullock et al., 2010; Fiedler et al., 2011; Rohrer et al., 2022). Where possible, mediation analyses may be helpful in revising and expanding the pathways discussed in this article, but my aim is not to encourage potentially problematic mediation analyses, as the overuse of this analytic technique is a known issue in the field of psychology.

Instead, my main goal is to draw attention to the importance of individuals’ satisfaction with outcomes of GAC as a key variable of interest in its own right, and I hope to encourage researchers to address the common implicit assumption that people are generally satisfied with their experiences of receiving GAC and the outcomes of this care. Research into people’s experiences of changes to their gendered embodiment as a result of GAC is essential in order to ensure that their needs and expectations are being met by the clinicians who provide them with care. If we rest on the assumption that so long as an individual is receiving any GAC whatsoever, their dysphoria is being adequately addressed, we do not hold clinicians to a high standard. Furthermore, we forgo any curiosity about and exploration of the diversity of individual desires and subjective definitions of what constitutes a good outcome of GAC.

Finally, I hope that this discussion may be helpful for people in countering arguments that the overall efficacy of GAC is unclear. If we frame the primary outcome of GAC as a physical change to the body, as opposed to more abstract outcomes such as gendered well-being, it is quite clear that GAC “works,” because the physical effects of exogenous hormones and the ability of surgeons to facilitate changes to the gendered body are well-established.

Conclusion

Future research on the pathways discussed in this article can provide an opportunity to more fully explore the embodied psychosocial experience of receiving gender-affirming medical care, specifically the degree to which individuals are satisfied with the GAC they have received. Most importantly, I hope that drawing attention to the physical changes that people experience through GAC can help ensure that gender-affirming procedures are, first and foremost, meeting the expectations of those who seek them.

John E. Castle
Department of Psychology, Stony Brook University, Stony
Brook, NY, USA
john.castle@stonybrook.edu

Funding Statement

The author reports there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author.