Do hormones and surgery improve the health of adults with gender incongruence? A systematic review of patient reported outcomes

Pliensak N., Suwan A., Panyakhamlerd K., Bumphenkiatikul T., Wainipitapong S.

Nolan B.J., Zwickl S., Locke P., Zajac J.D., Cheung A.S.

ImportanceTestosterone treatment is a necessary component of care for some transgender and gender-diverse individuals. Observational studies have reported associations between commencement of gender-affirming hormone therapy and improvements in gender dysphoria and depression, but there is a lack of data from randomized clinical trials.ObjectiveTo assess the effect of testosterone therapy compared with no treatment on gender dysphoria, depression, and suicidality in transgender and gender-diverse adults seeking masculinization.Design, Setting, and ParticipantsA 3-month open-label randomized clinical trial was conducted at endocrinology outpatient clinics and primary care clinics specializing in transgender and gender-diverse health in Melbourne, Australia, from November 1, 2021, to July 22, 2022. Participants included transgender and gender-diverse adults aged 18 to 70 years seeking initiation of testosterone therapy.InterventionsImmediate initiation of testosterone commencement (intervention group) or no treatment (standard care waiting list of 3 months before commencement). This design ensured no individuals would be waiting longer than the time to standard care.Main Outcomes and MeasuresThe primary outcome was gender dysphoria, as measured by the Gender Preoccupation and Stability Questionnaire. Secondary outcomes included the Patient Health Questionnaire-9 (PHQ-9) to assess depression and the Suicidal Ideation Attributes Scale (SIDAS) to assess suicidality. Questionnaires were undertaken at 0 and 3 months. The evaluable cohort was analyzed.ResultsSixty-four transgender and gender-diverse adults (median [IQR] age, 22.5 [20-27] years) were randomized. Compared with standard care, the intervention group had a decrease in gender dysphoria (mean difference, −7.2 points; 95% CI, −8.3 to −6.1 points; P < .001), a clinically significant decrease in depression (ie, change in score of 5 points on PHQ-9; mean difference, −5.6 points; 95% CI, −6.8 to −4.4 points; P < .001), and a significant decrease in suicidality (mean difference in SIDAS score, −6.5 points; 95% CI, −8.2 to −4.8 points; P < .001). Resolution of suicidality assessed by PHQ-9 item 9 occurred in 11 individuals (52%) with immediate testosterone commencement compared with 1 (5%) receiving standard care (P = .002). Seven individuals reported injection site pain/discomfort and 1 individual reported a transient headache 24 hours following intramuscular administration of testosterone undecanoate. No individual developed polycythemia.Conclusions and RelevanceIn this open-label randomized clinical trial of testosterone therapy in transgender and gender-diverse adults, immediate testosterone compared with no treatment significantly reduced gender dysphoria, depression, and suicidality in transgender and gender-diverse individuals desiring testosterone therapy.Trial RegistrationANZCTR Identifier: ACTRN1262100016864

Hill A.O., Cook T., McNair R., Amos N., Carman M., Hartland E., Lyons A., Bourne A.

van Leerdam T.R., Zajac J.D., Cheung A.S.

Gender-affirming hormone therapy (GAHT) is an essential part of gender affirmation for many transgender (including people with binary and nonbinary identities) individuals and although controlled s...

Novais Valente Junior C., Mesquita de Medeiros A.

Objective To verify the association between vocal perception and Common Mental Disorders (CMD) suspicion in trans women. Methods Cross-sectional observational study including 24 adult trans women with a minimum time of presentation as a woman of six months. The sampling of the subjects was supported by the "Snowball" technique. Three questionnaires were applied for data collection: sociodemographic and health data, Self-Reporting Questionnaire (SRQ-20) and Trans Woman Voice Questionnaire (TWVQ). The sociodemographic and health data collected were: age, marital status, education, smoking habits, speech therapy, use of hormones, and whether they had undergone Sex Reassignment Surgery (SRG). SRQ-20 was used for suspicion of CMD evaluation, such as depressive and anxiety symptoms. TWVQ is a vocal self-report questionnaire for trans women living the full-time gender role in which they self-identify. TWVQ has a minimum score of 30 points and a maximum of 120 points. Higher scores are associated with perceptions of a higher frequency of voice-related difficulties and psychosocial impacts. For statistical analysis, data were analyzed descriptively and statistically using Fisher's and Mann-Whitney's exact tests, both with a significance level of 5%. Results The average participants' age in this study was 28.2 years old (SD = 6.5 / minimum = 21 and maximum = 48); 83.3% were single; most (41.7%) were high school graduates; and most (95.83%) had not undergone Sex Reassignment Surgery. All subjects reported using hormones; 37.5% were smokers; 4.2% had undergone speech therapy; and the average number of years of experience in the female role was 8.8 years (SD = 7.2). The average TWVQ score was 55.4 points (SD = 4.3). Through SRQ-20, it was verified the prevalence of suspected CMD in 58.3% of the participants. The study results indicated that communicative dissatisfaction in trans women due to inconsistent voice with the recognized gender is associated with probable CMD such as depression and anxiety (P= 0.001). Conclusion Trans women who reported greater difficulties and voice-related effects in their lives had more symptoms of anxiety and depression. Although more research is needed, results indicate the need for inter-professional preventive and therapeutic actions directed towards assisting trans women. This fact encourages reflection on the care of this population and the role of health professionals, enhancing scientific production, clinical practice and the inclusion of the "transsexuality" theme in Speech Language and Hearing Sciences.

Ascha M., Sasson D.C., Sood R., Cornelius J.W., Schauer J.M., Runge A., Muldoon A.L., Gangopadhyay N., Simons L., Chen D., Corcoran J.F., Jordan S.W.

ImportanceTransgender and nonbinary (TGNB) adolescents and young adults (AYA) designated female at birth (DFAB) experience chest dysphoria, which is associated with depression and anxiety. Top surgery may be performed to treat chest dysphoria.ObjectiveTo determine whether top surgery improves chest dysphoria, gender congruence, and body image in TGNB DFAB AYA.Design, Setting, and ParticipantsThis is a nonrandomized prospective cohort study of patients who underwent top surgery between December 2019 and April 2021 and a matched control group who did not receive surgery. Patients completed outcomes measures preoperatively and 3 months postoperatively. This study took place across 3 institutions in a single, large metropolitan city. Patients aged 13 to 24 years who presented for gender-affirming top surgery were recruited into the treatment arm. Patients in the treatment arm were matched with individuals in the control arm based on age and duration of testosterone therapy.ExposuresPatients in the surgical cohort underwent gender-affirming mastectomy; surgical technique was at the discretion of the surgeon.Main Outcomes and MeasuresPatient-reported outcomes were collected at enrollment and 3 months postoperatively or 3 months postbaseline for the control cohort. The primary outcome was the Chest Dysphoria Measure (CDM). Secondary outcomes included the Transgender Congruence Scale (TCS) and Body Image Scale (BIS). Baseline demographic and surgical variables were collected, and descriptive statistics were calculated. Inverse probability of treatment weighting (IPTW) was used to estimate the association of top surgery with outcomes. Probability of treatment was estimated using gradient-boosted machines with the following covariates: baseline outcome score, age, gender identity, race, ethnicity, insurance type, body mass index, testosterone use duration, chest binding, and parental support.ResultsOverall, 81 patients were enrolled (mean [SD] age, 18.6 [2.7] years); 11 were lost to follow-up. Thirty-six surgical patients and 34 matched control patients completed the outcomes measures. Weighted absolute standardized mean differences were acceptable between groups with respect to body mass index, but were not comparable with respect to the remaining demographic variables baseline outcome measures. Surgical complications were minimal. IPTW analyses suggest an association between surgery and substantial improvements in CDM (–25.58 points; 95% CI, –29.18 to –21.98), TCS (7.78 points; 95% CI, 6.06-9.50), and BIS (–7.20 points; 95% CI, –11.68 to –2.72) scores.Conclusions and RelevanceTop surgery in TGNB DFAB AYA is associated with low complication rates. Top surgery is associated with improved chest dysphoria, gender congruence, and body image satisfaction in this age group.

Chaovanalikit T., Wirairat K., Sriswadpong P.

Abstract Introduction Previous studies have reported low quality of life scores and a high prevalence of depression among transgender women in Thailand; however, there is still little research on the effects of gender confirmation surgery among this population. Aim This study aims to prospectively evaluate the overall quality of life, self-esteem, and depression status among male-to-female transgender individuals in Thailand. Methods This prospective observational cohort study was conducted between January 2018 and December 2020 and included 41 participants who underwent gender confirmation surgery. All participants underwent a psychiatric evaluation and received 3 sets of questionnaires preoperatively and 6 months postoperatively to evaluate quality of life, self-esteem, and depression: the Thai abbreviated version of the World Health Organization quality of life questionnaire, the Rosenberg Self-Esteem Scale, and the Patient Health Questionnaire-9, respectively. We examined scores from each questionnaire and depression status before and after gender confirmation surgery, with P < .05 considered significant. Main Outcome Measure This study's primary outcomes measured quality of life, depression, and self-esteem before and after gender confirmation surgery. Results Thirty-seven participants completed all sets of questionnaires (response rate 90.2%). The mean age of the participants was 26.2 ± 4.7 years at the time of surgery. Five (13.5%) participants met the criteria for mild depression preoperatively, but none did postoperatively. There were no signs of major depressive disorder, suicidal ideation, or suicidal attempts in any of the participants. There was a significant improvement in quality of life (P < .001) and self-esteem (P < .001), as well as lower depression (P < .001) after gender confirmation surgery. The greatest quality of life improvement was related to participants’ sexual relationships. Conclusion Male-to-female gender confirmation surgery significantly contributes to improving quality of life, self-esteem, and depression in Thai transgender women. Persons diagnosed with gender dysphoria who intend to undergo gender confirmation surgery should be supported by healthcare providers in accessing the medical facilities and treatment needed to improve their quality of life.

Schoffer A.K., Bittner A.K., Hess J., Kimmig R., Hoffmann O.

To achieve long-term improvement in health care of transgender women, it is necessary to analyze all aspects of gender-confirming surgery, especially the relation of risks and benefits occurring in these procedures. While there are many studies presenting data on the urologic part of the surgery, there are just few data about complications and satisfaction with breast augmentation. This is a retrospective study using parts of the BREAST-Q Augmentation Questionnaire and additional questions for symptoms of capsular contracture and re-operations and analyzing archived patient records of all transwomen which were operated at University Hospital Essen from 2007 to 2020. 99 of these 159 patients (62%) completed the questionnaire after a median time of 4 years after surgery. Breast augmentation led to re-operations due to complications in 5%. The rate of capsular contracture (Baker Grad III–IV) in this population was 3%. Most patients (75%) rated high scores of satisfaction with outcome (more than 70 points) and denied to have restrictions due to their implants in their everyday life. All patients reported an improvement in their quality of life owing to breast augmentation. Breast augmentation by inserting silicon implants is a safe surgical procedure which takes an important part in reducing gender dysphoria.

Tordoff D.M., Wanta J.W., Collin A., Stepney C., Inwards-Breland D.J., Ahrens K.

Importance Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care. Objective To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality. Design, Setting, and Participants This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021. Exposures Time since enrollment and receipt of PBs or GAHs. Main Outcomes and Measures Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome. Results Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51). Conclusions and Relevance This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Filipov H., Kavla Y., Şahin S., Gökler M.E., Turan Ş.

Turban J.L., King D., Kobe J., Reisner S.L., Keuroghlian A.S.

Objective To examine associations between recalled access to gender-affirming hormones (GAH) during adolescence and mental health outcomes among transgender adults in the U.S. Methods We conducted a secondary analysis of the 2015 U.S. Transgender Survey, a cross-sectional non-probability sample of 27,715 transgender adults in the U.S. Using multivariable logistic regression adjusting for potential confounders, we examined associations between access to GAH during early adolescence (age 14–15), late adolescence (age 16–17), or adulthood (age ≥18) and adult mental health outcomes, with participants who desired but never accessed GAH as the reference group. Results 21,598 participants (77.9%) reported ever desiring GAH. Of these, 8,860 (41.0%) never accessed GAH, 119 (0.6%) accessed GAH in early adolescence, 362 (1.7%) accessed GAH in late adolescence, and 12,257 (56.8%) accessed GAH in adulthood. After adjusting for potential confounders, accessing GAH during early adolescence (aOR = 0.4, 95% CI = 0.2–0.6, p < .0001), late adolescence (aOR = 0.5, 95% CI = 0.4–0.7, p < .0001), or adulthood (aOR = 0.8, 95% CI = 0.7–0.8, p < .0001) was associated with lower odds of past-year suicidal ideation when compared to desiring but never accessing GAH. In post hoc analyses, access to GAH during adolescence (ages 14–17) was associated with lower odds of past-year suicidal ideation (aOR = 0.7, 95% CI = 0.6–0.9, p = .0007) when compared to accessing GAH during adulthood. Conclusion Access to GAH during adolescence and adulthood is associated with favorable mental health outcomes compared to desiring but not accessing GAH.

Pavanello Decaro S., Van Gils S., Van hoorde B., Baetens K., Heylens G., Elaut E.

Arianmehr T., Cheraghi Z., Ahmadpanah M., Mohammadi Y.

This study aimed to evaluate the quality of life (QOL) of transgender (trans) people in Iran. In this cross-sectional study, participants were included in the study using the snowball sampling technique. Two hundred thirty-five transgender people from different provinces of Iran were identified and agreed to participate in the study. To measure the QOL of these individuals, we used the short form of the QOL SF-36 questionnaire, which was completed as self-administered. In this study, the highest and lowest mean scores of trans individuals’ QOL belong to the physical functioning (88.59 ± 13.81) and bodily pain (30.78 ± 25.68) domains, respectively. Moreover, the mean scores of mental health, emotional role, vitality, general health, and bodily pain domains were less than 50. Reassignment surgery, vocation, and age were significantly associated with quality of life score (P < 0.05). Iranian transgender individuals lack appropriate QOL. It seems that gender reassignment surgery and job creation for these individuals improve their QOL.

Oles N., Darrach H., Landford W., Garza M., Twose C., Park C.S., Tran P., Schechter L.S., Lau B., Coon D.

To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment.Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress.A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes.Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications.Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.

Gümüşsoy S., Hortu İ., Alp Dal N., Dönmez S., Ergenoğlu A.M.

This study aimed to explore the pre- and postoperative differences in quality of life and perceived social support of Female-to-Male transsexual patients who underwent mastectomy and complete hysterectomy. Sixty-three Female-to-Male female individuals who underwent complete hysterectomy and mastectomy between November 2019 and November 2020 were included in this study. Data were collected using the Personal Information Form, Multidimensional Scale of Perceived Social Support, and the World Health Organization Quality of Life Scale Short Form. The pre- and postoperative perceived social support mean scores of patients were 57.2 ± 9.0 and 74.9 ± 7.3, respectively. The pre- and postoperative quality of life mean scores of patients were 76.9 ± 8.3 and 107.8 ± 10.1, respectively. There were statistically significant differences between the measurements ( p < .05). In addition, the patients whose education level was primary school, whose income was less than their expenditure, whose father was a primary school graduate, whose family had a strict family opinion on sexuality, whose family had a traditional view, and who had a high body mass index were found to have higher postoperative social support perceptions and quality of life. The patients’ postoperative quality of life and perceived social support improved after sex reassignment surgery.

Nolan B.J., Cheung A.S.