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Association Between Gender-Affirming Surgeries and Mental Health Outcomes

Educational Objective
To identify to what extent gender-affirming surgery is associated with better mental health outcomes among transgender and gender diverse people.
1 Credit CME
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.


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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Article Information

Corresponding Author: Anthony N. Almazan, BA, Harvard Medical School, 25 Shattuck St, Boston, MA 02215 (anthony_almazan@hms.harvard.edu).

Accepted for Publication: February 5, 2021.

Published Online: April 28, 2021. doi:10.1001/jamasurg.2021.0952

Author Contributions: Mr Almazan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Almazan.

Obtained funding: Keuroghlian.

Administrative, technical, or material support: Keuroghlian.

Supervision: Keuroghlian.

Conflict of Interest Disclosures: Dr Keuroghlian reported grants from Patient-Centered Outcomes Research Institute Contract AD-2017C1-6569 (PI: Sari L. Reisner) during the conduct of the study; in addition, Dr Keuroghlian stands to receive future royalties as editor of a forthcoming McGraw-Hill Education textbook on transgender and gender diverse care. No other disclosures were reported.

Funding/Support:This work was supported by contract AD-2017C1-6569 from the Patient-Centered Outcomes Research Institute (PI: Dr Sari L. Reisner).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the National Center for Transgender Equality for granting us access to the data from the 2015 US Transgender Survey.

Dhejne  C , Van Vlerken  R , Heylens  G , Arcelus  J .  Mental health and gender dysphoria: a review of the literature.   Int Rev Psychiatry. 2016;28(1):44-57. doi:10.3109/09540261.2015.1115753PubMedGoogle ScholarCrossref
Grant  J , Motter  L , Tanis  J. Injustice at every turn: a report of the National Transgender Discrimination Survey. 2011. Accessed October 11, 2020. https://www.transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf
Gilbert  PA , Pass  LE , Keuroghlian  AS , Greenfield  TK , Reisner  SL .  Alcohol research with transgender populations: a systematic review and recommendations to strengthen future studies.   Drug Alcohol Depend. 2018;186:138-146. doi:10.1016/j.drugalcdep.2018.01.016PubMedGoogle ScholarCrossref
Wheldon  CW , Wiseman  KP .  Tobacco use among transgender and gender non-conforming adults in the United States.   Tob Use Insights. 2019;12:X19849419. doi:10.1177/1179173X19849419PubMedGoogle Scholar
Reisner  SL , Poteat  T , Keatley  J ,  et al.  Global health burden and needs of transgender populations: a review.   Lancet. 2016;388(10042):412-436. doi:10.1016/S0140-6736(16)00684-XPubMedGoogle ScholarCrossref
Coleman  E , Bockting  W , Botzer  M ,  et al  Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.   Int J Transgenderism. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873Google ScholarCrossref
Berli  JU , Knudson  G , Fraser  L ,  et al.  What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review.   JAMA Surg. 2017;152(4):394-400. doi:10.1001/jamasurg.2016.5549PubMedGoogle ScholarCrossref
James  S , Herman  J , Rankin  S , Keisling  M , Mottet  L , Anafi  M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016. Accessed April 2, 2020. https://ncvc.dspacedirect.org/handle/20.500.11990/1299
Weissler  JM , Chang  BL , Carney  MJ ,  et al.  Gender-affirming surgery in persons with gender dysphoria.   Plast Reconstr Surg. 2018;141(3):388e-396e. doi:10.1097/PRS.0000000000004123PubMedGoogle ScholarCrossref
Canner  JK , Harfouch  O , Kodadek  LM ,  et al.  Temporal trends in gender-affirming surgery among transgender patients in the United States.   JAMA Surg. 2018;153(7):609-616. doi:10.1001/jamasurg.2017.6231PubMedGoogle ScholarCrossref
Pfafflin  F , Junge  A .  Sex reassignment thirty years of international follow-up studies SRS: a comprehensive review, 1961-1991.   International Journal of Transgenderism. Published online 1998.Google Scholar
Murad  MH , Elamin  MB , Garcia  MZ ,  et al.  Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes.   Clin Endocrinol (Oxf). 2010;72(2):214-231. doi:10.1111/j.1365-2265.2009.03625.xPubMedGoogle ScholarCrossref
Bränström  R , Pachankis  JE .  Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study.   Am J Psychiatry. doi:10.1176/appi.ajp.2019.19010080Google Scholar
Correction to Bränström and Pachankis.  Correction to Bränström and Pachankis.   Am J Psychiatry. 2020;177(8):734-734. doi:10.1176/appi.ajp.2020.1778correctionPubMedGoogle ScholarCrossref
Kessler  RC , Green  JG , Gruber  MJ ,  et al.  Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative.   Int J Methods Psychiatr Res. 2010;19(S1)(suppl 1):4-22. doi:10.1002/mpr.310PubMedGoogle ScholarCrossref
Tolles  J , Meurer  WJ .  Logistic regression: relating patient characteristics to outcomes.   JAMA. 2016;316(5):533-534. doi:10.1001/jama.2016.7653PubMedGoogle ScholarCrossref
Stoltzfus  JC .  Logistic regression: a brief primer.   Acad Emerg Med. 2011;18(10):1099-1104. doi:10.1111/j.1553-2712.2011.01185.xPubMedGoogle ScholarCrossref
Bennett  DA .  How can I deal with missing data in my study?   Aust N Z J Public Health. 2001;25(5):464-469. doi:10.1111/j.1467-842X.2001.tb00294.xPubMedGoogle ScholarCrossref
Schneiders  M.   Values and Preferences of Transgender People: A Qualitative Study. World Health Organization; 2014:65.
Jokić-Begić  N , Lauri Korajlija  A , Jurin  T .  Psychosocial adjustment to sex reassignment surgery: a qualitative examination and personal experiences of six transsexual persons in croatia.   ScientificWorldJournal. 2014;2014:960745. doi:10.1155/2014/960745PubMedGoogle Scholar
McGuire  JK , Doty  JL , Catalpa  JM , Ola  C .  Body image in transgender young people: Findings from a qualitative, community based study.   Body Image. 2016;18:96-107. doi:10.1016/j.bodyim.2016.06.004PubMedGoogle ScholarCrossref
Keuroghlian  AS , Reisner  SL , White  JM , Weiss  RD .  Substance use and treatment of substance use disorders in a community sample of transgender adults.   Drug Alcohol Depend. 2015;152:139-146. doi:10.1016/j.drugalcdep.2015.04.008PubMedGoogle ScholarCrossref
Wilson  EC , Chen  Y-H , Arayasirikul  S , Wenzel  C , Raymond  HF .  Connecting the dots: examining transgender women’s utilization of transition-related medical care and associations with mental health, substance use, and HIV.   J Urban Health. 2015;92(1):182-192. doi:10.1007/s11524-014-9921-4PubMedGoogle ScholarCrossref
Blosnich  JR , Lehavot  K , Glass  JE , Williams  EC .  Differences in alcohol use and alcohol-related health care among transgender and nontransgender adults: findings from the 2014 behavioral risk factor surveillance system.   J Stud Alcohol Drugs. 2017;78(6):861-866. doi:10.15288/jsad.2017.78.861PubMedGoogle ScholarCrossref
Byne  W , Bradley  SJ , Coleman  E ,  et al; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder.  Report of the American Psychiatric Association task force on treatment of gender identity disorder.   Arch Sex Behav. 2012;41(4):759-796. doi:10.1007/s10508-012-9975-xPubMedGoogle ScholarCrossref
Almazan  AN , Benson  TA , Boskey  ER , Ganor  O .  Associations between transgender exclusion prohibitions and insurance coverage of gender-affirming surgery.   LGBT Health. 2020;7(5):254-263. doi:10.1089/lgbt.2019.0212PubMedGoogle ScholarCrossref
Arnold  JD , Nelson  AE , Loubier  EM .  Trends in insurance coverage for gender-affirming surgeries.   JAMA Surg. 2018;153(10):972. doi:10.1001/jamasurg.2018.2120PubMedGoogle ScholarCrossref
Kuzon  WM  Jr , Sluiter  E , Gast  KM .  Exclusion of medically necessary gender-affirming surgery for America’s armed services veterans.   AMA J Ethics. 2018;20(4):403-413. doi:10.1001/journalofethics.2018.20.4.sect1-1804PubMedGoogle Scholar
Nobili  A , Glazebrook  C , Arcelus  J .  Quality of life of treatment-seeking transgender adults: a systematic review and meta-analysis.   Rev Endocr Metab Disord. 2018;19(3):199-220. doi:10.1007/s11154-018-9459-yPubMedGoogle ScholarCrossref
Bränström  R , Pachankis  JE .  Toward rigorous methodologies for strengthening causal inference in the association between gender-affirming care and transgender individuals’ mental health: response to letters.   Am J Psychiatry. 2020;177(8):769-772. doi:10.1176/appi.ajp.2020.20050599PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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