Gender-Affirming Surgery Linked to Positive MH Outcomes Over Time
Abstract
Over a 10-year follow-up period, an individual’s odds of receiving treatment for a mood or anxiety disorder decreased by 8% for each year since his or her last gender-affirming surgery.
See erratum at bottom of story.
People who are transgender face a slew of challenges every day, including discrimination and difficulties accessing the health care they need to align physically with their gender identity. Though several professional organizations, including APA, recommend that physicians consider providing medical interventions for those who want them, cost is often an insurmountable barrier in the United States.
Yet research shows that people who are transgender benefit when they get the medical interventions they seek, and a study of the entire Swedish population published October 4 in AJP in Advance further reinforces that point. Among those in Sweden who received gender-affirming surgery, the likelihood of being treated for a mood or anxiety disorder decreased by 8% for each year since their last surgery over a 10-year follow-up period.
According to the study, transgender individuals were about three times as likely to have received prescriptions for antidepressant or anxiolytic medication and more than six times as likely to have been hospitalized after a suicide attempt. These findings were not surprising considering the challenges the population faces, said Richard Bränström, Ph.D.
Richard Bränström, Ph.D., an associate professor at the Karolinska Institutet in Sweden and research affiliate at the Yale School of Public Health, and John E. Pachankis, Ph.D., an associate professor of public health at the Yale School of Public Health, collected health information from the 2,679 people diagnosed with gender incongruence (defined as a diagnosis of either transsexualism or gender identity disorder) in Sweden between 2005 and 2015. They used the Swedish Total Population register, which included 9.7 million people.
“We had a unique possibility with the registry that we have here in Sweden,” said Bränström. “Most studies of this population have been quite small, often just samples collected in the clinic with short follow-up times, and it’s unknown how representative those samples are of the transgender population overall.”
To determine the mental health outcomes of Sweden’s transgender population over 10 years, researchers first gathered data on the type and year of gender-affirming treatments obtained by those with gender incongruence diagnoses from 2005 to 2015. The study’s outcome measures were psychiatric outpatient health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt.
“[W]e then investigated the odds of mood and anxiety disorder treatment and hospitalization following a suicide attempt as a function of years since initiation of hormone or hormone-suppressing treatment and since last gender-affirming surgery,” the authors wrote.
The findings tracked a significant reduction in the odds of receiving treatment for a mood or anxiety disorder and hospitalization following a suicide attempt after the individual’s last gender-affirming surgery. There was, however, no relationship between the years since initiation of hormone treatment and the likelihood of mental health treatment.
The findings align, on a larger scale, with those of many smaller studies: People who are transgender benefit when they are able to receive gender-affirming medical interventions. Over 70% of those diagnosed with gender incongruence during the study period received hormone treatment (including androgen-suppressing and -blocking medication), and 48% received gender-affirming surgical treatment (usually chest surgery or surgery of the reproductive organs).
The authors noted several limitations to the study, particularly that the criteria used to define the transgender population may not capture the full spectrum of those who identify as transgender. They also pointed out that those diagnosed with gender incongruence are naturally exposed to treatment settings that may predispose them to seeking mental health treatment.
That may be part of the reason why, Bränström noted, even 10 years after their last gender-affirming surgery, those with gender incongruence diagnoses were still significantly more likely to be treated for a mood or anxiety disorder than the general population. But that finding also likely reflects, Bränström added, that living as a transgender individual naturally comes with stigma-related stress or minority stress.
Eric Yarbrough, M.D., chair of APA’s Council on Minority Mental Health and Health Disparities and past president of the Association of LGBTQ Psychiatrists, said that he believes the findings are applicable to the United States. “It’s only going to give us more evidence to show insurance companies that these types of surgeries and treatments should be paid for,” Yarbrough said.
“We are in a culture war right now,” said Jack Drescher, M.D., who is a clinical professor of psychiatry at Columbia University and served on the DSM-5 Work Group on Sexual and Gender Identity Disorders. He is also the author of Psychoanalytic Therapy and the Gay Man and emeritus editor of the Journal of Gay and Lesbian Mental Health. “There are still some who believe people should not be able to have those services, so for those of us who are treating people in these populations, a study that shows that people who get treatment feel better is no surprise. That we have to prove it today is the sad thing.”
The study was supported by the Swedish Research Council and the Swedish Research Council for Health, Working Life, and Welfare. ■
“Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study” is posted here.
Erratum
After the article “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study” by Richard Bränström, Ph.D., and John E. Pachankis, Ph.D. (doi: 10.1176/appi.ajp.2019.19010080), was published online on October 4, 2019 in the American Journal of Psychiatry, some letters containing questions on the statistical methodology employed in the study led the Journal to seek statistical consultations. The results of these consultations were presented to the study authors, who concurred with many of the points raised. Upon request, the authors reanalyzed the data to compare outcomes between individuals diagnosed with gender incongruence who had received gender-affirming surgical treatments and those diagnosed with gender incongruence who had not. While this comparison was performed retrospectively and was not part of the original research question given that several other factors may differ between the groups, the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison. Given that the study used neither a prospective cohort design nor a randomized controlled trial design, the conclusion that “the longitudinal association between gender-affirming surgery and lower use of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them” is too strong. Finally, although the percentage of individuals with a gender incongruence diagnosis who had received gender-affirming surgical treatments during the follow-up period is correctly reported in Table 3 (37.9%), the text incorrectly refers to this percentage as 48%. A corrected article will be posted on August 1, along with a postpublication discussion captured in the Letters to the Editor section.
