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Page 10 of 13 Larshans et al. Plast Aesthet Res. 2025;12:7 https://dx.doi.org/10.20517/2347-9264.2024.154

from social workers and mental health professionals. Additionally, patients continue to be monitored by
gender surgeons (as long as needed), endocrinologists (for lifelong follow-up), and general practitioners.
This integrated approach ensures that patients receive comprehensive care, with timely referrals and access
to mental health professionals when needed. This strategy was already in place before the study was
conducted, and this study served to confirm the effectiveness of the existing routine.

These findings highlight the contrast between the transgender population and the general Swedish
population, with only 3% of the latter reporting having considered taking their own lives at some point
[12]
during the previous year . This discrepancy underscores the severe mental health challenges that
transgender individuals face. Higher rates of thoughts of self-harm or suicidal ideation may be attributed to
[40]
various psychological and social factors, including stigma and discrimination .

The World Medical Association’s Declaration of Geneva stresses that physicians are ethically obliged to
prioritize the health and well-being of their patients, without discrimination on any grounds . This ethical
[41]
obligation highlights the responsibility to treat all patients, ensuring that those with mental health
conditions are not denied the care they need. Comprehensive medical care must be accessible to every
individual, regardless of their mental health status, suicidal ideation, or self-harming.

Our study also explored the overall psychological health of the participants. As shown in Figure 1, most
respondents expressed varying degrees of satisfaction with their mental health. GAS, such as vaginoplasty,
has been linked to improvements in mental health . Interestingly, despite these positive outcomes, 72% of
[9]
the participants self-reported some form of mental illness [Table 4]. This suggests that many participants
experienced positive psychological outcomes after surgery, even though they reported ongoing mental
health issues. This may indicate that mental health diagnoses were made prior to surgery, and that these
issues persisted even after physical transition. Thus, while the GAS may improve aspects of mental well-
being, it does not entirely resolve pre-existing mental health conditions. Additionally, participants may
perceive their current state as being more meaningful and joyful despite their mental health diagnoses,
highlighting the complex interplay between physical transitions and mental health. However, these remain
speculations, as we did not conduct a preoperative study to compare the mental health status before and
after surgery. Future research should aim to provide a more holistic understanding of psychological
outcomes following gender-affirming surgeries that address both immediate and long-term psychological
needs.

Relationship between life satisfaction, self-harm, mental illness, and surgical complications
This manuscript is the first in a trilogy, specifically focusing on life satisfaction and self-harm. The second
manuscript will address mental illness and QoL (also presenting Body-Image scale - BI-1), while the third
will examine surgical complications and techniques. An integrated discussion will be provided in the
manuscript on complications.

Regarding revision surgeries, most consisted of minor procedures, such as scar revisions, clitoral hood
reconstruction, labia reduction, or vaginal dilation. Therefore, the reported 30% rate of revision surgeries,
when considering the indications for surgery, does not correlate with self-harm or suicidal ideation. Instead,
this revision rate should be compared to other centers where procedures such as episiotomy and clitoral
hood reconstruction are performed in nearly 100% of cases. Although the manuscript dedicated to
complications is still in progress, preliminary data suggest that the incidence of major complications in our
cohort is exceptionally low, with rectovaginal fistula occurring in only 1.5% of cases.