Transgender Adults' Mental Health Improves With Desired Surgeries

Nancy A. Melville

April 28, 2021

Transgender adults who have undergone desired gender-affirming surgical transition show significant improvements in mental health, with reduced rates of psychological distress and suicidality, compared with those who have not received surgery, according to results from the largest study of its kind on the issue.

"To our knowledge, this is the first large-scale, controlled study to demonstrate an association between gender-affirming surgery and improved mental health outcomes," the authors write in an article published online April 28 in JAMA Surgery.

"It was quite surprising to see significantly better mental health outcomes across every examined measure, including suicide attempts, among those who received all of their desired surgeries," lead author Anthony N. Almazan, BA, an MD/MPH candidate at Harvard Medical School and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, told Medscape Medical News.

"It was also striking to observe that the magnitudes of these associations were so much stronger compared to those in the group that received only some of their desired surgeries," he said.

The findings are from an analysis that Almazan and senior author Alex S. Keuroghlian, MD, MPH, an associate professor of psychiatry at Harvard Medical School and director of the National LGBTQIA+ Health Education Center at the Fenway Institute, Boston, Massachusetts, conducted. They analyzed data on 27,715 transgender and gender-diverse adults across the United States (including US territories and US military bases abroad) who participated in the US Transgender Survey from August to September 2015.

After adjustment for sociodemographic factors and other types of gender-affirming care, those who reported having undergone one or more types of gender-affirming surgery at least 2 years prior to taking the survey (12.8%) had significantly lower rates of past-month psychological distress (assessed with the Kessler Psychological Distress Scale; adjusted odds ratio [aOR], 0.58), lower rates of past-year smoking (aOR, 0.65), and lower rates of past-year suicidal ideation (aOR, 0.56; all P < .001), compared with those who expressed a desire to have one or more types of gender-affirming surgery but had not yet done so (59.2%).

"The observed associations between gender-affirming surgery, psychological distress, and suicide risk reinforce previous small-sample studies suggesting that gender-affirming surgery improves mental health and quality of life among transgender and gender diverse people," the authors write.

Most respondents in the study (81.1%) were between the ages of 18 and 44 years, and 82.1% identified as White. Overall, 38.8% identified as transgender women, 32.5% as transgender men, and 26.6% as nonbinary.

Previous research has shown that 41% of transgender people attempt suicide over the course of their life, that 33% use tobacco, and that 27% to 61% engage in binge drinking.

Results Suggest a Dose-Response Relationship

The primary analysis showed no statistically significant associations between gender-affirming surgeries and improvements in past-month binge alcohol use or past-year suicide attempts.

However, a post hoc analysis that compared respondents who had undergone all of their desired gender-affirming surgeries (n = 2448) with respondents who had received only some desired surgeries (n = 3331) showed a significant reduction in the odds of past-month binge alcohol use as well as all of the other adverse mental health outcomes (P < .001 for all).

"[The findings] suggest a potential dose-response relationship between surgical gender affirmation and mental health outcomes," Almazan said. "To our knowledge, this is the first study to suggest such a relationship."

In light of the substantially lower percentage of transgender patients who had received all desired gender-affirming surgical procedures compared with those who desired surgery but had not received it (12.8% vs 59.2%), the findings should further support efforts to improve access to patients desiring the surgery, the authors add.

"For every adverse mental health outcome, the percentage of respondents who endorsed it was lower in the exposure group than in the control group," they state.

"An Important Addition to the Literature"

In commenting on the study, Laura Erickson-Schroth, MD, an assistant professor of psychiatry at Columbia University Medical Center and consulting psychiatrist with the Hetrick-Martin Institute for LGBTQ Youth, in New York City, noted that "this study has some significant strengths that make it an important addition to the literature.

"This is the largest study of its kind by far," she told Medscape Medical News. "It also has the benefit of comparing those who have had surgeries with those who want them, rather than with all those who have not had surgeries."

Erickson-Schroth agreed that the study underscores that many more transgender people are interested in surgeries than have access to them.

"My hope is that studies like this one will provide the evidence that insurance companies and health providers need to make surgeries more accessible to those who desire them," she said.

Erickson-Schroth added that she has seen first hand the improvements that come about when patients are able to undergo their desired surgeries.

"I'm not surprised at all about the results," she said. "I work with trans young people at Hetrick-Martin Institute for LGBTQ Youth in New York City, and many of my clients who have had surgeries have had significant improvements in their depressive symptoms, anxiety, self-confidence, and sense of self."

The authors of an accompanying editorial note that the mental health screening necessary to be a candidate for gender-affirming surgery could confound the outcomes.

Nevertheless, "this report contributes additional evidence to support the efficacy of gender-affirming surgery in alleviating dysphoria," they write.

"Mental health outcomes are among the most vital end points to study, given the fundamental intent of gender-affirming surgery is to provide patients with relief from gender dysphoria and improvement of psychosocial distress.

"Much of the data on this topic come from observational studies that lack either control groups or adequate sample size," they write.

The study received funding from the Patient-Centered Outcomes Research Institute. Co-author Keuroghlian stands to receive future royalties as editor of a forthcoming McGraw-Hill Education textbook on transgender and gender diverse care. Erickson-Schroth and the editorialists have disclosed no relevant financial relationships.

JAMA Surg. Published April 28, 2021. Abstract

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