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Original Investigation
April 28, 2021

Association Between Gender-Affirming Surgeries and Mental Health Outcomes

Author Affiliations
  • 1Harvard Medical School, Boston, Massachusetts
  • 2Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 3The Fenway Institute, Fenway Health, Boston, Massachusetts
  • 4Department of Psychiatry, Massachusetts General Hospital, Boston
JAMA Surg. 2021;156(7):611-618. doi:10.1001/jamasurg.2021.0952
Key Points

Question  Are gender-affirming surgeries associated with better mental health outcomes among transgender and gender diverse (TGD) people?

Findings  In this secondary analysis of the 2015 US Transgender Survey (n = 27 715), TGD people with a history of gender-affirming surgery had significantly lower odds of past-month psychological distress, past-year tobacco smoking, and past-year suicidal ideation compared with TGD people with no history of gender-affirming surgery.

Meaning  These findings support the provision of gender-affirming surgeries for TGD people who seek them.

Abstract

Importance  Requests for gender-affirming surgeries are rapidly increasing among transgender and gender diverse (TGD) people. However, there is limited evidence regarding the mental health benefits of these surgeries.

Objective  To evaluate associations between gender-affirming surgeries and mental health outcomes, including psychological distress, substance use, and suicide risk.

Design, Setting, and Participants  In this study, we performed a secondary analysis of data from the 2015 US Transgender Survey, the largest existing data set containing comprehensive information on the surgical and mental health experiences of TGD people. The survey was conducted across 50 states, Washington, DC, US territories, and US military bases abroad. A total of 27 715 TGD adults took the US Transgender Survey, which was disseminated by community-based outreach from August 19, 2015, to September 21, 2015. Data were analyzed between November 1, 2020, and January 3, 2021.

Exposures  The exposure group included respondents who endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses. The comparison group included respondents who endorsed a desire for 1 or more types of gender-affirming surgery but denied undergoing any gender-affirming surgeries.

Main Outcomes and Measures  Endorsement of past-month severe psychological distress (score of ≥13 on Kessler Psychological Distress Scale), past-month binge alcohol use, past-year tobacco smoking, and past-year suicidal ideation or suicide attempt.

Results  Of the 27 715 respondents, 3559 (12.8%) endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses, while 16 401 (59.2%) endorsed a desire to undergo 1 or more types of gender-affirming surgery but denied undergoing any of these. Of the respondents in this study sample, 16 182 (81.1%) were between the ages of 18 and 44 years, 16 386 (82.1%) identified as White, 7751 (38.8%) identified as transgender women, 6489 (32.5%) identified as transgender men, and 5300 (26.6%) identified as nonbinary. After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing 1 or more types of gender-affirming surgery was associated with lower past-month psychological distress (adjusted odds ratio [aOR], 0.58; 95% CI, 0.50-0.67; P < .001), past-year smoking (aOR, 0.65; 95% CI, 0.57-0.75; P < .001), and past-year suicidal ideation (aOR, 0.56; 95% CI, 0.50-0.64; P < .001).

Conclusions and Relevance  This study demonstrates an association between gender-affirming surgery and improved mental health outcomes. These results contribute new evidence to support the provision of gender-affirming surgical care for TGD people.

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    1 Comment for this article
    EXPAND ALL
    Unrecognised confounding may explain differences in mental health outcomes
    David Curtis, MBBS MD PhD FRCPsych | University College London
    A major concern about this paper is that the two groups compared – those who have had surgery and those who might want it some day – are really nothing like each other.

    In the results section the authors refer to differences in percentages for various measures but fail to highlight the magnitude of these differences:

    More than three times as many subjects who had surgery are over 44 (43.4% v. 13.6%)

    More than twice as many subjects who had surgery had a degree (64.0% v. 29.3%)

    More than twice as many subjects who had
    not had surgery were unemployed (15.1% v. 5.7%)

    Three times as many subjects who had not had surgery were nonbinary (30.2% v. 9.6%)

    Nearly twice as many subjects who had surgery had household income over $100,000 (23.6% v. 12.6%)

    Twice as many subjects who had surgery were heterosexual (22.0% v. 10.5%)

    These drastic differences between the two groups make it clear that the answers to the questions regarding surgery serve to identify quite different subsets of the survey respondents.

    In the discussion section the authors do admit the possibility that the study may be subject to unmeasured confounding but not enough weight is given to this issue. The two groups are so radically different that we really cannot assume that the multivariate analyses carried out allow us to conclude that differences in psychopathology are likely the result of surgical intervention. We can certainly agree with the authors that there is a need for larger probability-based surveys and more comprehensive health data collection. We cannot agree that the results provide strong evidence that gender-affirming surgery is causally associated with improved mental health outcomes.
    CONFLICT OF INTEREST: None Reported
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