Richard Bränström, Ph.D., John E. Pachankis, Ph.D.
Published Online:4 Oct 2019 https://doi.org/10.1176/appi.ajp.2019.19010080
Abstract
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 prescriptions 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 associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98).
Conclusions:
In this first total population study of transgender 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.
Numerous studies indicate that transgender individuals—that is, individuals who experience incongruity between their sex assigned at birth and their current gender identity—are at particular risk of psychological distress and associated impairment (e.g., suicidality) (1–3). This elevated risk is hypothesized to stem at least in part from transgender individuals’ elevated exposure to stigma-related stress, also known as minority stress (4, 5), and it can also result from the stress associated with a lack of gender affirmation (i.e., the accurate recognition and validation of one’s gender identity) (6). ICD-11 (7) specifies that individuals experiencing persistent discordance between their experienced gender and their assigned sex meet diagnostic criteria for gender incongruence.
To alleviate the stress of persistent discordance between experienced gender and assigned sex, an increasing number of transgender individuals who experience gender incongruence seek gender-affirming medical interventions, including hormone replacement therapy and gender-affirming surgeries (8). The World Professional Association for Transgender Health’s Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People recommends consideration of these interventions for affirming transgender individuals’ gender and alleviating gender-related stress (9).
Despite professional recommendations to consider gender-affirming medical interventions for transgender individuals who experience gender incongruence, the effect of such interventions on long-term mental health is largely unknown. Available evidence stems mainly from small samples utilizing cross-sectional designs and self-reported treatment exposures and mental health outcomes (2, 10, 11). A meta-analysis that aggregated data across nearly two dozen small-sample studies (10), mostly relying on cross-sectional designs, found positive associations between self-reports of receiving both hormone therapy and gender-affirming surgery and mental health. Several more recent uncontrolled studies of the effects of hormone replacement therapy on transgender individuals’ mental health have found that transgender individuals’ mental health improved for up to 24 months after initiating hormone therapy (11, 12).
Because of previous studies’ limitations, including short assessment periods and the fact that existing probability-based surveys do not routinely assess transgender status or other aspects of gender diversity, insufficient evidence exists regarding associations between length of time since receiving gender-affirming interventions and treatment for psychiatric disorders among the transgender population. In fact, no probability-based evidence exists regarding even the prevalence of mood and anxiety disorder treatment among transgender individuals compared with the general population (1).
The limitations of previous research in terms of nonrepresentative sampling, self-reported measurement, and limited follow-up periods can be overcome with national health registry data sets that include clinician-derived assessment of gender incongruence and complete records of psychiatric and gender-affirming treatment and utilization data in an entire population. In the one known study to use a population-based design to investigate psychiatric morbidity among transgender individuals (N=324), individuals who had legally changed their gender and had a diagnosis of gender incongruence associated with an inpatient hospital visit in Sweden between 1973 and 2003 were at higher risk of suicide attempts, suicide-related mortality, and psychiatric hospitalization compared with age- and reassigned-gender-matched controls (13). The study did not report the prevalence of mood and anxiety disorder treatment among those receiving gender-affirming treatment compared with the total population or as a function of length of time since receiving gender-affirming treatment. Furthermore, the proportion of individuals receiving gender-affirming treatments in Sweden has increased nearly exponentially since 2003 (8, 14). Similar recent increases in referrals for gender-affirming treatments have been reported in other countries around the world (15–18).
In this study, we took advantage of the Swedish Total Population Register (19), linked to the Swedish National Patient Register and the Swedish Prescribed Drug Register, to ascertain the prevalence of mood and anxiety disorder health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt among the entire Swedish population as a function of gender incongruence diagnosis, gender-affirming hormone and surgery utilization, and length of time since receiving gender-affirming treatments. This data set permitted identification of all individuals in Sweden seeking gender-affirming treatments between January 1, 2005, and December 31, 2015. Although not all transgender individuals seek gender-affirming treatments and not all treatment-seeking transgender individuals meet diagnostic criteria for gender incongruence, findings from this unique data opportunity have timely implications for documenting the mental health of transgender individuals seeking gender-affirmative treatment and ways in which the medical profession can support this increasingly visible population.
Methods
This total population prospective study included all individuals living in Sweden on December 31, 2014, as identified in the Swedish Total Population Register. Using de-identified personal identification numbers (a unique number assigned to all Swedish residents), we linked sociodemographic information with National Patient Register information on health care usage between January 1, 2005, and December 31, 2015, and Prescribed Drug Register information on prescribed and purchased medication between July 1, 2005, and December 31, 2015. The study was approved by the Regional Ethics Committee in Stockholm (no. 2017/1736–31).
Gender Incongruence Diagnosis
Using the Swedish National Patient Register, we classified all individuals in Sweden according to whether they had received a diagnosis of gender incongruence, as defined by the diagnostic system applied in Sweden during the study period (i.e., a diagnosis of either transsexualism [ICD-10 code F64.0] or gender identity disorder [ICD-10 codes F64.8, F64.9]) during an inpatient or specialized outpatient visit between January 1, 2005, and December 31, 2015. The two diagnoses used to define gender incongruence at the time of the study are not fully equivalent but capture largely overlapping populations (20). In Sweden during the study period, a diagnosis of either transsexualism or gender identity disorder was required for accessing gender-affirming treatment (e.g., gender-affirming hormone treatment, hormone-suppressing or -blocking medication treatment, mastectomy with chest contouring, hair removal, vocal cord surgery, speech therapy, genital surgery) and was given after an approximately yearlong evaluation, following a national consensus program (14, 21). Adolescents could receive the same gender-affirming treatments as adults but could not receive genital surgery before age 18 (22).
Outcome Measures
This study’s outcome measures were psychiatric outpatient health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt between January 1, 2015, and December 31, 2015. Restricting the outcome assessment period to one year, 2015, the most recent available, removes potential confounding by secular trends in treatment utilization and transgender acceptance and visibility. Each psychiatric outpatient visit was coded by the treating physician with a primary diagnosis from ICD-10 (23) and up to 20 supplementary ICD-10 diagnostic codes. Using these codes, we classified all individuals as having received treatment for any or no mood disorders (codes F30–F39) or anxiety disorders (codes F40–F42). Prescribed medication use was obtained from the Swedish Prescribed Drug Register, which contains information regarding all prescribed and purchased medications nationwide for all individuals. Individuals were categorized into any use or no use of antidepressant and anxiolytic medication according to the Anatomical Therapeutic Chemical (ATC) Classification system (codes N06A and N05B). All inpatient health care visits were similarly coded by the treating physician using ICD-10, indicating a primary cause of hospitalization and up to 30 supplementary causes. Using these codes, we classified all individuals as having been hospitalized after a suicide attempt (versus not) using the ICD-10 codes for intentional self-harm (codes X60–X84).
Covariates
Sociodemographic information was drawn from the Swedish Total Population Register in December 2014 and included current legal gender, age, country of birth, level of education, urbanicity, and household income.
Gender-Affirming Treatment Utilization
For individuals with a gender incongruence diagnosis at any visit, we assessed the type and year of gender-affirming treatment, both hormone treatment and surgery. Information about hormone treatment, including androgen-suppressing and -blocking medication, was obtained from the Swedish Prescribed Drug Register between July 1, 2005, and December 31, 2015. All medications prescribed to individuals who had received a gender incongruence diagnosis were coded as gender-affirming if they were feminizing hormone medication (i.e., estrogens [ATC codes G03C, L02AA], progestogen [G03D]), masculinizing hormone medication (i.e., androgens [G03B]), or androgen-suppression or -blocking medication (i.e., testosterone-5-alpha reductase inhibitors [G04CB], antiandrogens [G03H], gonadotropin-releasing hormone analogues [G03GA, L02AE, H01CA], antigonadotropin-releasing hormones [H01CC], and spironolactone [C03DA01]). For each individual with a gender incongruence diagnosis who received prescriptions for any of these medications, we calculated the number of years since initiation.
Gender-affirming surgery was coded using information about all inpatient surgical procedures received by individuals with a gender incongruence diagnosis in the National Patient Register between January 1, 2005, and December 31, 2015. All surgical procedures associated with a gender incongruence diagnosis performed during this period were coded by type of surgery using the Nordic Medico-Statistical Committee Classification of Surgical Procedures (16): breast or dermatological chest surgery (codes H and QB), surgery of the reproductive organs (codes K and L), dermatological surgery (code Q), and laryngeal surgery (code DQ).
Statistical Analysis
We first examined sociodemographic differences between individuals with a gender incongruence diagnosis and the rest of the population in Sweden. We then compared the prevalence of any mood and anxiety disorder treatments (i.e., psychiatric outpatient health care visits and prescribed psychiatric medication) between individuals receiving gender-affirming treatments and the rest of the population in Sweden during 2015, using logistic regression. Among individuals with a gender incongruence diagnosis, we then investigated the odds of mood and anxiety disorder treatment and hospitalization following a suicide attempt (occurring in 2015) as a function of years since initiation of hormone or hormone-suppressing treatment and since last gender-affirming surgery. We examined years since last gender-affirming surgery because gender-affirming surgery is often a lengthy process involving several distinct procedures before gender affirmation is attained.
All analyses were conducted using SPSS, version 24 (IBM, Armonk, N.Y.), and adjusted for current legal gender, age, country of birth, level of education, urbanicity, and household income.
Results
Of the total Swedish population on December 31, 2014 (N=9,747,324), 2,679 had received a diagnosis of gender incongruence between January 1, 2005, and December 31, 2015 (Table 1). Those diagnosed with gender incongruence were significantly younger on average than the rest of the population (t=19.94, p<0.001), and they were more likely to have a current legal female gender than male gender (χ2=4.54, p=0.03). Individuals with a gender incongruence diagnosis were more likely to have a university education (χ2=12.77, p<0.001), to have a lower household income (t=30.61, p<0.001), to live in a larger city (χ2=61.95, p<0.001), and to have been born outside of Europe (χ2=32.33, p<0.001).
CORRECTIONS & CRITIQUE:
