Effects of Gender Affirming Surgery on the Quality of Life of Transgender Women in Chiang Mai Province, Thailand

Abstract

Gender affirming surgery (GAS) helps individuals to achieve a physical presence consistent with their gender identity. In this study, we explored the decision, expectation, experience, satisfaction, and quality of life (QOL) of transgender women (TGWs) who have undergone GAS and compared their QOL with transfeminine individuals (TFs) who have not and are seeking to do so in Thailand. The median overall QOL score of the TGWs who have undergone GAS was slightly higher than that of the TFs who have not (95 (92–103) vs. 92 (86–98); p = 0.003), which was also reflected in the specific domains of psychological health, social relationships, and environmental health, the exception being physical health. Not being financially prepared was the most relevant reason for delaying undergoing GAS among the TFs who have not undergone it and want to do so. In addition, more than half of the TGWs who have undergone GAS regretted not being socially accepted after surgery. Although the difference between the QOLs of the two groups is statistically significant, the clinical significance should be further investigated to provide more insight. In addition, the higher QOL of TGWs might not solely be due to having undergone GAS.

Introduction

In the age of globalization, gender diversity encompassing people who are transgender, lesbian, gay, binary, and others has become more visible in society as well as more prevalent in media such as films and books. TGWs are now highly visible in Thai society compared to in previous decades, which tends to be more obvious in the urban rather than the rural setting (UNDP & USAID, 2014).

Gender transitioning is now easier with modern medical practices such as gender affirming surgery (GAS) (Weinforth et al., 2019), which helps individuals to achieve a physical presence consistent with their gender identity or gender experience (van de Grift et al., 2018). GAS from male to female consists of genital surgery (vaginoplasty) and non-genital surgery, for instance breast augmentation, voice, and facial features feminization (Chokrungvaranont & Tiewtranon, 2004). Gender dysphoria (GD) refers to a marked and persistent incongruence between the gender assigned at birth and gender identity, which causes feelings of discomfort and distress. In Thailand, TGWs must be diagnosed with GD by at least two psychiatrists before undergoing genital GAS (Center of Excellence in Transgender Health (CETH) & Chulalongkorn University, 2021). The requests for surgical intervention for transgender individuals have been steadily increased for several years (Ettner, 2018). Currently, Thailand is very famous and internationally recognized in the field of genital surgery, and the quality, affordability, and satisfactory hospitalization for GAS has resulted in it becoming a major growth industry in Thailand (Chokrungvaranont et al., 2014). In this study, the term of GAS refers to genital GAS or vaginoplasty which is the prime surgery from male to female.

Gender diversity, homosexuality, and transgender identity in Thailand have become a tolerated subculture (UNDP & USAID, 2014), with several non-cisgender individuals having been successful in their careers, especially in the entertainment and mass media industry (Chokrungvaranont et al., 2014). In 2012, the military removed the term “permanent mental disorder” and replaced it with “gender identity does not match the gender assigned at birth” in the military service exemption document for TGWs (UNDP & MSDHS, 2018). However, some barriers caused by national legislation, public policies, and social attitudes and discrimination toward the non-cisgender population still remain. In terms of legislation, TGWs who have undergone GAS have not been allowed to change their legal gender marker (Ocha, 2012), which has led to many TGWs being unable to obtain regular employment in areas such as the civil service and facing many obstacles for healthcare access, international travel, and making legal transactions. Moreover, transfeminine individuals (TFs) still encounter persistent stigma, discrimination, and exclusion by society, especially in employment and career opportunities, which has led to many of them setting up their own businesses, or becoming freelance (Suriyasarn, 2014) or sex industry workers (UNDP, 2020), where they can express themselves more freely (Suriyasarn, 2014). These issues can have unfavorable effects on the psychological functioning (Wernick et al., 2019), social acceptance (Winter, 2011), and quality of life (Suriyasarn, 2014) of TFs.

Quality of life (QOL) is one of the indexes representing the well-being of individuals consisting of 4 domains including physical health, psychological health, social relationships, and environmental health (Mahatnirunkul et al., 1998). Most previous studies have been focused on comparing the QOL before and after GAS of TGWs diagnosed with gender dysphoria (van de Grift et al., 2018; Özata Yıldızhan et al., 2018; Cardoso da Silva et al., 2016) or comparing TGWs’ QOL with cisgender women (Motmans et al., 2012; Breidenstein et al., 2019; Lindqvist et al., 2017), transgender men (Motmans et al., 2012), and cisgender men (Valashany & Janghorbani, 2018). Although Motmans et al. (2012) and Castellano et al. (2015) found no difference between the QOL of TGWs and the general population, other researchers have indicated that transgender people with GD have a lower QOL than the cisgender population (Newfield et al., 2006; de Vries et al., 2014, Valashany & Janghorbani, 2018). The results of a previous study comparing the QOL of people with GD with and without a history of GAS indicate that GAS improved their QOL (Özata Yıldızhan et al., 2018). The results from a follow-up study in Brazil conducted among 47 TGWs indicate that after GAS, the QOL improved in the psychological and social relationships domains but was diminished in the physical health and level of independence domains (Cardoso da Silva et al., 2016). In 2018, van de Grift et al. (2018) revealed significant improvement in the QOL of TGWs having undergone GAS compared with those who have not. The results from a previous study in Thailand intimate that individuals who are the youngest member of a family and/or live in a family in which a cisgender woman plays a prominent role without the help of a cisgender man were more likely to become TFs (Winter, 2006). In a recent study among TGWs in Chiang Mai, Gooren et al. (2013) found that although using transgender-inducing hormones without medical supervision was not related to the functional health and mental well-being of TGWs, it was related to the permanence of wearing feminine clothes. Furthermore, their social functioning and general mental health were affected by acceptance/rejection by their siblings.

Contrary to the advantages of GAS, TGWs can face several psychological, social, and environmental issues pertaining to satisfaction with GAS outcomes and responses from family, friends, and society. These issues can affect the feelings, roles, and relationships of TGWs that are related to their mental health (Iwamoto et al., 2019; Wernick et al., 2019). Therefore, the first objective of this study was to assess the QOL of TGWs who have undergone GAS and transfeminine individuals who have not and are seeking to do so, and then investigate the difference in QOL between the two groups. The second objective was to analyze the QOL of TGWs according to the time elapsed since undergoing GAS. We also explored the influence of deciding to undergo GAS among TGWs who have and TFs who have not undergone it. The expectation of TFs who have not undergone GAS before deciding to undergo it and the satisfaction among TGWs who have already undergone GAS was also examined. We believe that gathering insight into the impact of previous problems and unsatisfactory GAS results, especially genital surgery, will help improve preoperative information and support people at risk of dissatisfactory outcomes in the Thai context.

Methods

Participants and setting

This was a cross-sectional study involving 42 TGWs and 39 TFs who have and have not undergone GAS, respectively, which is 81% of all clients seeking care related to gender transitioning or sexually transmitted infection screening at Mplus Foundation clinics between August 2019 and August 2020. The Mplus medical technology clinic is an organization established in 2011 working on HIV prevention and lesbian, gay, bisexual, transgender, and questioning (LGBTQ) rights among key populations (men who have sex with men, TGWs, and sex workers) that is funded by USAID and managed by Family Health International (FHI 360) and the National Health Security Office (NHSO).

Participants who were older than 18 years of age, could read and understand the Thai language, were either TGWs who underwent GAS at least 6 months ago or TFs who have not undergone GAS who rated at least one point on the desire to undergo GAS scale, and voluntarily agreed to participate and disclose their personal information for the study were included in this study. The only exclusion criterion was children was born with ambiguous genitalia who had been diagnosed as having differences in sexual development (León et al., 2019; Ono & Harley, 2013). Participants were screened, gave consent, and were asked to complete the questionnaire during their regular clinical care visits. The participants were compensated with 300 baht (approximately 10 USD) for their time filling in the questionnaire.

This study protocol was approved by the ethical committee of the Faculty of Medicine, Chiang Mai University, Thailand (REC no. 219/2019).

Data collection and measurements

The questionnaire used in this study was separated into the in-depth interview and the QOL self-reported. The in-depth interview questionnaire consisted of three parts: (1) socio-demographic information; (2) the decision, expectation, experience, and satisfaction of the TGW after having undergone GAS; (3) the decision and expectation of TFs wanting to undergo GAS. The participants took 10–15 minutes to complete the interview with an expert staff member who, as well as being a mental health counselor and/or an LGBTQ healthcare provider at the Mplus foundation, is an expert in conducting in-depth interviews.

Socio-demographics: the participants were asked about their age, educational level, occupation, parental status, and relationship status and whether they wear feminine clothing, take hormones, and/or have undergone breast augmentation surgery and/or GAS.

Decision, expectation, experience, and satisfaction with undergoing GAS: their reasons for undergoing GAS, information-seeking, relevant factors about the decision, affirming expectation, operational cost, satisfaction, and recovery duration.

Decision and expectations of TF individuals who have not undergone GAS: the desire to undergo GAS, their age when first considering undergoing GAS, the reason for the delay in undergoing GAS, what information is needed to decide to undergo GAS, their expectations after GAS, and their mental state if they cannot undergo GAS.

QOL assessment: this outcome was measured by using the brief World Health Organization QOL questionnaire in Thai (WHOQOL-BRIEF-THAI). This tool comprises 26 items on a 5-point ordinal scale consisting of four domains, including physical health (7 items: mobility, daily activities, functional capacity, energy, pain, and sleep), psychological health (6 items: self-image, negative thoughts, a positive attitude, self-esteem, mentality, learning ability, memory concentration, religion, and mental state), social relationships (3 items: personal relationships, social support, and sex life), and environmental health (8 items: financial resources, safety, health and social services, the physical living environment, opportunities to acquire new skills and knowledge, recreation, the general environment, and transportation). Each item in the WHOQOL-BRIEF-THAI instrument requires the respondents to rate their feelings for each domain. These include “How satisfied are you with your health?”, “How much do you need medical treatment to function in your daily life?”, “How much do you enjoy life?”, “How much are you able to accept your bodily appearance?”, “How often do you have negative feelings such as feeling blue, despair, anxiety, and/or depression?”, etc. The overall score ranges from 26–130: 26–60 reveals a poor QOL, 61–95 a moderate QOL, and > 95 a good QOL. The WHOQOL-BRIEF-THAI revealed good reliability (Cronbach’s alpha value of 0.84) and moderate validity (a correlation coefficient of 0.65) compared to the WHOQOL-100 Thai edition (Mahatnirunkul et al., 1998).

Statistical analysis

Descriptive statistics were used for the characteristics of the study population. Continuous variables are presented as medians and interquartile ranges (IQRs), while categorical variables are presented as frequencies and percentages. A Shapiro-Wilk test was performed to assess normality. Mann-Whitney U tests and Chi-squared or Fisher’s exact test were used to compare differences between the characteristics and QOL of TGWs and TFs without GAS. A p-value of less than 0.05 was considered to be statistically significant. All analyses were performed using Stata 14 (StataCorp, College Station, Texas, USA).

Results

Of the 81 participants, 42 individuals were TGWs who have undergone GAS and 39 were TFs who have not, with median (IQR) ages of 30 (27–37) and 25 (20–30) years old, respectively. Nearly half of the TFs who have not undergone GAS (41%) were students. The monthly income of the TFs who have not undergone GAS was significantly lower than that of the TGWs who have (15,000 (9,000–15,000) versus 19,000 (12,000–25,000) Thai baht (approximately 500 (300–5,000) versus 633 (400–833) USD), respectively; p = 0.002). The majority of participants were currently taking hormones: TFs without GAS (66.7%) and TGWs (85.7%). Most participants dressed as women all the time (84.6% for TFs without GAS and 95.2% for TGWs). Most of the TFs without GAS (87.2%) had not undergone breast augmentation surgery, while most TGWs (81%) had (p < 0.001). The median ages at breast augmentation surgery for TFs without GAS and TGWs were 25 (23–38) and 23 (20–25) years old, respectively (Table 1).

Table 1. Characteristics of the participants.

Characteristic (n (%) or Median [IQR])	TFs without GAS (n = 39)	TGWs (n = 42)	p-value^a
Median age (years)	25 [20–30]	30 [27–37]	<0.001^*
Educational level
Not attended university	19 (48.7%)	21 (50.0%)	0.908
Undergraduate or higher	20 (51.3%)	21 (50.0%)
Occupation
Student	16 (41.0%)	–	<0.001^*
Employee	7 (18.0%)	9 (23.8%)
Officer	11 (28.2%)	8 (20.5%)
Business owner	5 (12.8%)	15 (38.5%)
Others	–	7 (18.0%)
Revenue (THB)	15000 [9000–15000]	19000 [12000–25000]	0.0021^*
Parental status
Together	29 (78.4%)	36 (85.7%)	0.394
Divorced	8 (21.6%)	6 (14.3%)
Siblings
Yes	16 (41.0%)	27 (64.3%)	0.036^*
No	23 (59.0%)	15 (35.7%)
Partner
Yes	8 (20.5%)	9 (21.4%)	0.919
No	31 (79.5%)	33 (78.6%)
Seen violence committed by the family?
Yes	18 (46.2%)	15 (35.7%)	0.339
No	21 (53.9%)	27 (64.3%)
Experienced violence from a family member?
Yes	11 (28.2%)	15 (35.7%)	0.469
No	28 (71.8%)	27 (64.3%)
Hormonal use
Yes	26 (66.7%)	36 (85.7%)	0.145
No	7 (17.9%)	4 (9.5%)
Used to	6 (15.4%)	2 (4.8%)
Wearing feminine clothes
All the time	33 (84.6%)	40 (95.2%)	0.168
Sometimes	4 (10.3%)	–
Never	2 (5.1%)	2 (4.8%)
Breast augmentation
Yes	5 (12.8%)	34 (81.0%)	<0.001^*
No	34 (87.2%)	8 (19.0%)
Median age at breast augmentation (years)	25 [23–28]	23 [20–25]	0.134

%, percentage; IQR, interquartile range; TFs, transfeminine individuals; TGWs, transgender women; GAS, gender affirming surgery; n, frequency.

^a p-value derived from a Mann-Whitney U test for continuous variables and Fisher’s exact test for categorical variables.

^* p-value < 0.05.

The main reason for GAS was to be completely female (85.7% for TFs without GAS and 97.6% for TGWs). Only 2.4% of TGWs reported that they decided to have GAS after being convinced by a friend. The major influencer for deciding to undergo GAS was themselves (87.5% for TFs without GAS and 90.9% for TGWs). Most of the participants had ever searched for information about GAS (76.9% for TFs without GAS and 78.6% for TGWs). Most TFs without GAS had searched via the internet (42.2%), while most TGWs had ask someone who had experienced GAS (50%). Only a few participants (9.4% of TFs without GAS and 1.9% of TGWs) had asked for information from a transgender healthcare provider (Table 2).

Table 2. Decision, expectation, and satisfaction concerning gender affirming surgery.

Characteristic (n (%) or Median [IQR])	TFs without GAS (n = 39)	TGWs with GAS (n = 42)
Reason for undergoing GAS
To be completely female	36 (85.7%)	41 (97.6%)
To fulfill a relationship	3 (7.1%)	–
For work	3 (7.1%)	–
To convince friends	–	1 (2.4%)
Decision influencer (multiple answers)
Yourself	35 (87.5%)	40 (90.9%)
Partner	3 (7.5%)	2 (4.5%)
Friends	1 (2.5%)	2 (4.5%)
Family	1 (2.5%)	1 (2.3%)
Have you ever searched the information about GAS?
Yes	30 (76.9%)	33 (78.6%)
No	9 (23.1%)	9 (21.4%)
If yes, where did you search for the information (multiple answers)?
Internet	27 (42.2%)	15 (28.8%)
Experienced person	24 (37.5%)	26 (50.0%)
Physician/surgeon	7 (10.9%)	10 (19.2%)
Transgender healthcare worker	6 (9.4%)	1 (1.9%)
TFs who have not undergone GAS
Median wanted score	9 [7–10]
Median wanted age (years)[IQR]	18 [15–20]
The reason for not undergoing GAS at present (multiple answers)
Financial readiness	33 (53.2%)
Time readiness	5 (8.1%)
Physical readiness	7 (11.3%)
Require more information	7 (11.3%)
Concern over pain after GAS	5 (8.1%)
Concern over results of GAS	4 (6.5%)
Concern over social acceptance	1 (1.6%)
The most useful information to make the decision (multiple answers)
Cost of GAS	22 (40.7%)
Side effects of GAS	19 (35.2%)
Surgeon and clinic	13 (24.1%)
Expectation after GAS (multiple answers)
Being a complete woman	32 (60.4%)
Partner satisfaction	4 (7.5%)
Acceptance for work	8 (15.1%)
Acceptance from society	8 (15.1%)
Others	1 (1.9%)
Mental status if cannot undergo GAS
Depressed	1 (2.6%)
Dissatisfied	9 (23.1%)
Unaffected	29 (74.4%)
TGWs who have undergone GAS
Time since GAS (years)		6.5 [5–12]
Decision factor (multiple answers)
Surgeon’s fame		16 (28.1%)
Surgeon’s portfolio		18 (31.6%)
Friend’s recommendation		21 (36.8%)
Others		2 (3.5%)
Financial resources for GAS
Own budget		30 (66.7%)
Loan		4 (8.9%)
Partner		3 (6.7%)
Family		6 (13.3%)
Others		2 (4.4%)
GAS cost (baht)		120000 [80000–160000]
GAS satisfaction
Extremely satisfied		9 (21.4%)
Very satisfied		29 (69.0%)
Satisfied		4 (9.5%)
Sexual satisfaction after GAS
Better than before		34 (85.0%)
Same as before		6 (15.0%)
The most satisfaction after GAS
Being a complete woman		40 (78.4%)
Partner’s satisfaction		5 (9.8%)
Acceptance at work		3 (5.9%)
Acceptance from society		2 (3.9%)
Others		1 (2.0%)
The most regret after GAS
Social acceptance		21 (61.8%)
Side effects from GAS		13 (38.2%)
Recovery duration (months) [IQR]		3 [1–3]

IQR, interquartile range; TFs, transfeminine individuals; TGWs, transgender women; GAS, gender affirming surgery.

The median score for the desire to undergo GAS for TFs without GAS was 9 (7–10) points at a median age of 18 (15–20) years old. The major reason for delaying GAS was the cost (53.2%), followed by preparing for the operation or the need to find more information (11.3%). Only 1.6% of TFs without GAS reported that they had not undergone GAS due to concerns about social acceptance. The cost of GAS (40.7%) and the effects of GAS (35.2%) were the most useful information for GAS decision-making among TFs without GAS. Most TFs without GAS (60.4%) expected to be completely female after GAS, while 7.5% reported that they expected satisfaction from their partners. Some TFs without GAS reported that they would be dissatisfied (23.1%) or depressed (2.6%) if they could not undergo GAS (Table 2).

For the TGWs who have undergone GAS, the median time length since surgery was 6.5 (5–12) years. The most relevant factor for deciding to undergo GAS among TGWs was a friend’s recommendation (36.8%), the performance statistics of the surgeon (28.1%), and the fame of the surgeon (28.1%). Most TGWs used their own money for GAS (66.7%), while some of them attained it from their families (13.3%), a loan (8.9%), or a partner (6.7%). The median cost of GAS for TGWs in this study was 120,000 (80,000–160,000) Thai baht (approximately 4,000 (2,667–5,333) USD). The median duration for recovery after GAS was 3 (1–3) months. Most of them were very satisfied with the results of GAS (69%) and had better sexual satisfaction than beforehand (85%). The most satisfaction after GAS was with being completely female (78.4%), although most TGWs reported that they regretted not being socially accepted after GAS (61.8%) (Table 2).

The Cronbach’s alpha coefficients of 0.887 indicate the good reliability of the WHOQOL-BRIEF-THAI questionnaire in the present study. The overall QOL was significantly different between TFs without GAS and TGWs (92 (86–98) versus 95 (92–103); p = 0.003). Differences in QOL were present in the psychological (p = 0.009), social relationships (p = 0.025), and environmental (p = 0.012) aspects. The QOL of TGW participants who had undergone GAS at least 10 years ago was slightly lower than those who had undergone GAS more recently (95 (92–96) vs. 99 (92–96); p = 0.212). However, the QOL was found to be significantly different only in the social relationship aspect (12 (11–13) versus 11 (10–12) points for TGWs who undergone GAS >10 years and those with a lower period, respectively) (Table 3).

Table 3. QOL comparison of the participants.

QOL Score (Medians [IQRs])	Identity			Time since GAS^b
	TFs without GAS (n = 39)	TGWs with GAS (n = 42)	p-value^a	< = 10 years (n = 23)	> 10 years (n = 17)	p-value^a
Physical	25 [22–26]	24.5 [23–28]	0.3787	25 [24–29]	24 [23–26]	0.1754
Psychological	21.5 [19–23]	23 [21–26]	0.0087^*	23 [21–27]	22 [21–24]	0.5169
Social relationship	11 [10–12]	11.5 [10–13]	0.0246^*	12 [11–13]	11 [10–12]	0.0072^*
Environment	28 [25–29]	30 [27–32]	0.0122^*	30 [28–33]	30 [27–30]	0.4253
Overall	92 [86–98]	95 [92–103]	0.0032^*	99 [92–108]	95 [92–96]	0.2116

^a p-value derived from Mann-Whitney U test. IQR, interquartile range; TFs, transfeminine individuals; TGWs, transgender women; GAS, gender affirming surgery.

^b There were 2 missing values for the time since GAS among TGWs.

^* p-value < 0.05.

Discussion

The QOL scores for most participants (both the TGWs who have undergone GAS and the TF individuals who have not) were quite high (> 90 out of 130). However, one transfeminine individual reported having a poor QOL in terms of mental health. TGWs had a better QOL in most aspects (psychological health, social relationship, and environmental health), with physical health being the exception. In contrast, TFs who have not undergone GAS had a moderate QOL for various aspects. All of the TGWs in our study reported that they were satisfied with the outcomes after having undergone GAS. This is consistent with the results of a previous study in which most TGWs had their expectations of life as a woman fulfilled after undergoing GAS (Hess et al., 2014).

The results of several studies show that TGWs reported improved QOL and mental health after having undergone GAS in aspects such as happiness, perceived social support from the family, social relationships, and psychological-related QOL, as well as lower psychological distress, suicidal ideation, etc. (Cardoso da Silva et al., 2016; Fallahtafti et al., 2019; Özata Yıldızhan et al., 2018). Consistent with this, our results also show that the QOL among TGWs who have already undergone GAS was slightly higher than that of the TFs who have not and wish to do so. However, both the statistical and clinical significance of this finding should be further investigated and confirmed in a well-designed study with a larger sample size. According to the mental health service for transgenders in Thailand, all transgenders must be evaluated by two psychiatrists to confirm that they do not have a psychiatric condition that could be attributed to their desire to undergo GAS. If any underlying psychiatric conditions ambiguously affect the desire to undergo GAS, then the psychiatrist will advise against it. The recommendations for transgender healthcare services in Thailand were launched by The Royal College of Psychiatrists of Thailand in 2013 and are relevant to The Thai Handbook of Transgender Healthcare Services Center of Excellence in Transgender Health, Chulalongkorn University (Center of Excellence in Transgender Health (CETH), Chulalongkorn University, 2021). This practice explains why some transgenders who already have mental health problems when they are psychiatrically evaluated before undergoing GAS tend to have a worse mental health status. Indeed, they are treated by the psychiatrists until they are deemed to be at least stable enough to understand the consequences and make an informed decision about undergoing GAS, and adhere to the standard post-operative care. Although the difference between the QOL values of the two groups is statistically significant, the clinical significance should be further investigated to provide more insight. In addition, the higher QOL of TGWs might not solely be due to having undergone GAS. Further analysis with a larger group of participants while adjusting for obvious confounding factors (e.g., age, economic status, career status, etc.) should be conducted in the future to elucidate the role of other potential factors and psychological aspects influencing the QOL of these study populations other than GAS.

Readiness at the time of GAS could be related to the difference in QOL after surgery. In a previous study in Iran, Valashany and Janghorbani (2018) found that economic status affects QOL. Thailand’s annual household income per capita in 2020 was 7,189.6 USD (approximately 599 USD per month) (Office of the National Economic & Social Development Council, 2022) whereas the average cost of GAS in Thailand was around 3,710–4,636 USD (Rawikul & Lattipongpun, 2020). In our study, the monthly income of the TGWs who have undergone GAS was higher than the average whereas that of the TF participants was quite a bit lower; this combined with the high cost of GAS could comprise a major barrier to undergoing GAS among the latter. This is also reflected in our results: more than a half of the TFs who have not undergone GAS reported that they have not yet done so due to not being financially prepared. Our results show that the income between these groups of participants was significantly different (p = 0.002). In addition, nearly half of the TF participants who have not undergone GAS and wishes to do so were students whereas none of the TGW participants were. A follow-up study examining the impact of the readiness of TF individuals to undergo GAS should be conducted.

In a previous study conducted among TGWs in Chiang Mai, Thailand, Gooren et al. (2013) found that rejection by their siblings resulted in lower scores for social functioning and general mental health. Although acceptance by family members and peers was not included in our study, the TGWs who have undergone GAS presented with a slightly higher and significantly different QOL score in the social relationship domain compared to the TF individuals who have not (11.5 (10–13) vs. 11 (10–12) points; p = 0.025). Thus, a further study including the acceptance by family members and peers criterion should be conducted to further investigate this finding.

Surprisingly, we found that more than 60% of TGWs who have undergone GAS regretted not being socially accepted after surgery. Presently, Thai TGWs cannot legally change their gender on their ID cards, passports, and official documents, thereby presenting difficulties for them to integrate into society (Chokrungvaranont et al., 2014). Since the legal doctrine concerning changing gender has not yet been established in Thailand, we could not determine the influence of this factor. However, the effect of legal support on QOL and mental health among TGWs should be included in a future study.

The findings from a previous study suggest that increased duration after GAS results in a higher QOL (Breidenstein et al., 2019) whereas we inconsistently found a lower QOL score for TGWs who underwent GAS more than 10 years ago compared to those undergoing GAS more recently. This might be because of a difference in the quality of the surgery a decade ago compared with the more recent technologically advanced procedure (Moisés da Silva et al., 2021). However, in another previous study of TGWs who have undergone GAS in Sweden, Lindqvist et al. (2017) also reported a decrease in QOL score according to time since the procedure for both the physical and mental health domains. Moreover, the findings from a previous study also indicate that the physical health of TGWs does not intrinsically improve as a result of GAS (Riggs et al., 2014), which is consistent with our findings in which the QOL was unaffected by physical aspects when comparing TGWs who have undergone GAS with TFs who have not. This might be because of improvements in medical technology and surgical procedures that have led to fewer physical problems after surgery. Although Akhavan et al. (2021) affirmed that genital surgery complication rates are low, Moisés da Silva et al. (2021) reported minor post-GAS complications such as granulation in the surrounding tissue, introital stricture of the neovagina and major ones such as urethral meatus stenosis and hematoma/excessive bleeding. Although most of the participants in our study were able to have regular sexual relations and achieve satisfaction after undergoing GAS, long-term sexual and urinary tract problems can occur. Hence, a follow-up study to examine any association between these factors and QOL among TGWs who have undergone GAS while adjusting for time since the operation and the quality of the GAS procedure should be conducted.

There might be other psychological issues among TGWs related to undergoing GAS. In a previous study in the United States, Restar et al. (2020) suggested that a legal change of gender on government-identification documents was significantly associated with lower negative emotional responses such as depression, anxiety, somatization, psychiatric distress, and being upset by gender-based mistreatment and improved mental health among the transgender population. While the focus of our study was only on QOL, psychological factors other than those in response to GAS and consequential outcomes could also influence the QOL. Further study should be conducted to take these into account.

The limitations of this study are the location of the participants and differences in their characteristics. Since most of the participants resided in the upper northern region of Thailand, the entire transgender population of Thailand was not represented and so the results cannot be generalized for the whole country. Participants were only recruited at Mplus Foundation clinics in Chiang Mai, Thailand, and so other suitable individuals who did not visit one of them during the recruitment period could not be involved in the study. Moreover, we only recruited individuals who could read and understand the Thai language, and so the QOL of foreign transgender individuals who had undergone GAS in Thailand was not covered in this study. In addition, the two populations of this study primarily differed in demographic characteristics, such as age, occupation, and especially, income. The majority of the TF individual group were students whose income was less than the TGWs, most of whom operated their own businesses. This difference as well as the cost of GAS could have influenced the decision to undergo QOL. In addition, due to the limited number of participants, adjusting for possible confounding factors to examine the factors associated with QOL via logistic regression analysis could not be applied. Controlling for obvious confounding factors (e.g., age, income, being a student, etc.) would be interesting in a future study with a larger sample size. Although we are aware that sexual and urinary problems can arise after undergoing GAS, this issue was not investigated in the present study. An investigation of the long-term effects among TGWs who have undergone GAS should be considered in a future study.

In summary, TGWs who have already undergone GAS had a slightly higher QOL score in terms of psychological health, social relationships, and environmental health but not physical health. Not being financially prepared was the most pertinent reason for delaying undergoing GAS among TFs who have not undergone it and want to do so. In addition, more than half of the TGWs who have undergone GAS regretted not being socially accepted after surgery. The clinical significance of the improvement in QOL and the long-term effects of having undergone GAS were not encompassed in this study. Further well-designed analysis with a larger group of participants while adjusting for obvious confounding factors should be conducted in the future to investigate the role of other potential factors and psychological aspects influencing the QOL of these study populations other than GAS.

Acknowledgments

We thank all patients who participated in this study. We thank all staffs in the MPlus Foundation for all support.

Disclosure statement

The authors have no competing interest to disclose.

Additional information

Funding

This work was supported by Faculty of Science and Chiang Mai University.