At least 1.4 million Americans identify as transgender. Like everyone, transgender people experience their identity in a variety of ways: In some cases, that realization of identity is paired with the distressing experience of gender dysphoria, also called gender incongruence. Gender incongruence is accompanied by the sense that one’s experienced gender and their assigned sex are mismatched.
In a world that’s often unfriendly to people outside the heteronormative mold, grappling with gender incongruence can be painful. It can lead to a higher risk of mental disorders, including depression and anxiety. Trans people often bear more stress, social discrimination, rejection, and violence than non-trans people.
A study published Friday in the American Journal of Psychiatry shows that, compared to cisgender people, individuals with gender incongruence are six times as likely to visit a health care facility for mood or anxiety disorders, three times as likely to receive prescriptions for antidepressants or anti-anxiety medication, and six times as likely to be hospitalized after attempting suicide.
The study didn’t just pinpoint the severity of mental health risks of people who have been diagnosed with gender incongruence: It revealed that one intervention has a powerful effect on mitigating these risks more than others. The research shows that gender-affirming surgeries, which alter different parts of people’s anatomy, lead to long-term mental health benefits, more so than hormone therapy.
No person’s experience with gender incongruence or transition towards their chosen gender identity is the same. Some people choose to change their name, the way they dress, or the pronouns they use to express their chosen gender identity. Others choose to undergo hormone therapy by taking estrogen, testosterone or hormone suppressants, or elect to have gender-affirming surgery by altering their breasts, chests, Adam’s apple, or genitals. Some don’t seek treatment at all or make any externally visible changes. It’s up to the individual to decide how and when to express their chosen gender.
The research, led by Richard Branstrom, Ph.D., and John E. Pachankis, Ph.D., is the largest study to date to examine the mental health of transgender individuals diagnosed with gender incongruence. It identified 2,679 people from the total Swedish population who received a diagnosis of gender incongruence between 2005 and 2015.
In turn, more than 70 percent of this group received hormone treatment while 48 percent had undergone gender-affirming surgery. Ninty-seven percent of those who went through surgery also received hormone treatment. Less than one-third received neither treatment.
The researchers wanted to see how different treatments impact affected a person’s likelihood of using mental health treatments. The team totaled health care visits for mood and anxiety disorders, antidepressant and anti-anxiety prescriptions, as well as hospitalizations after an attempted suicide.
This process revealed that, in this study sample, more time passed after undergoing gender-affirming surgery was associated with a lower likelihood of seeking mental health treatment. That suggests that gender-affirming surgery boosts mental health over time, more so than hormone treatment or no treatment at all. Specifically, the odds of receiving some form of mental health care were reduced by 8 percent for every year since undergoing surgery.
In some countries, gender-affirming surgeries are unaffordable, inaccessible, or socially stigmatized.
Meanwhile, in the United States hospitals can refuse to perform gender-affirming surgeries or hormone treatments on the basis of religion. While gender-affirming surgery is widely accepted as “a medically necessary intervention” for people with gender incongruence, a 2018 article in the AMA Journal of Ethics notes that Veterans Health Administration (VHA) policies, which prohibit gender-affirming surgeries at VA facilities or using VA funding, deny “medically necessary care to veterans, causing harm to individual patients and reinforcing discrimination and prejudicial treatment of a minority population.”
In this new study, the authors write that their research “provides timely support for policies that ensure coverage of gender-affirming treatments.” When surgery is denied, they note, individuals can suffer — both physically and mentally.
Objective: Despite professional recommendations to consider gender-affirming hormone and surgical interventions for transgender individuals experiencing gender incongruence, the long-term effect of such interventions on mental health is largely unknown. The aim of this study was to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population.
Methods: This study used the Swedish Total Population Register (N=9,747,324), linked to the National Patient Register and the Prescribed Drug Register. Among individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015 (N=2,679), mental health treatment in 2015 was examined as a function of length of time since gender-affirming hormone and surgical treatment. Outcome measures were mood and anxiety disorder health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt.
Results: Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received pre- scriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was as- sociated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98).
Conclusions: In this first total population study of transgen- der individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.