Gender-affirming care may improve mental health of transgender youths

Transgender and nonbinary youths who received gender-affirming care were significantly less likely to have moderate or severe depression and suicidality than those who did not, according to findings published in JAMA Network Open.

“Our study builds on a robust scientific-evidence base that access to gender-affirming care is critically important for the mental health and well-being of trans youth,” Diana M. Tordoff, MPH, a PhD student in epidemiology at the University of Washington, told Healio. “Our findings demonstrate that puberty blockers (PBs) and gender-affirming hormones (GAHs) can mitigate depression and suicidality over the relatively short period of 1 year, and that delays in prescribing PBs and hormones may in fact worsen mental health symptoms for trans youth.”

In a prospective observational cohort study, Tordoff and colleagues investigated changes in mental health among transgender and nonbinary adolescents and young adults who sought gender-affirming care. The researchers assessed participants for depression, anxiety and suicidality with the Patient Health Questionnaire 9-Item and the Generalized Anxiety Disorder 7-Item scales.

In total, 104 youths aged 13 to 20 years in an urban multidisciplinary gender clinic were followed from August 2017 to June 2018. The mean age was 15.8 years and 64.4% of the youths were white. The study cohort included 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26%), 10 nonbinary or gender-fluid individuals (9.6%) and four individuals who did not specify their gender identity (3.8%).

Tordoff and colleagues reported that 80.8% of the study cohort completed the surveys after 3 and 6 months of follow up and 62.5% completed the surveys after 1 year of follow up.

Prevalence of mental health issues

Overall, 56.7% of the youths had moderate to severe depression, 50% had moderate to severe anxiety and 43.3% reported thoughts of self-harm or suicidality at baseline.

After 1 year, 66.3% of the youths had received PBs, GAHs or both interventions. The remaining participants did not receive either intervention, according to the researchers.

After adjusting for confounding factors, Tordoff and colleagues reported 60% lower odds of depression (adjusted OR = 0.4; 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 received gender-affirming therapy compared with the youths who did not. However, there was no significant association between PBs or GAHs and anxiety (aOR = 1.01; 95% CI, 0.41-2.51).

“Our findings have important policy implications, suggesting that the recent wave of legislation restricting access to gender-affirming care may have significant negative outcomes in the well-being of [transgender and nonbinary] youths,” Tordoff and colleagues wrote.

Recently, Texas Gov. Greg Abbott has issued a directive to report any instances of transgender minors receiving gender-affirming medical care, which he said constitutes as “child abuse under existing Texas law.”

In response, the ACP issued a statement strongly opposing “governmental interference in the patient-physician relationship that prevents physicians from providing their patients with evidence-based medical services.”

Meanwhile, there are other legislative and governmental efforts that directly aim to criminalize gender-affirming care for trans youth, Tordoff said.

“These efforts most certainly will have profound immediate and long-term negative impacts on the well-being of trans youth and their families, both by increasing stigma and discrimination experienced by these youth and denying them access to critical, lifesaving, evidence-based health care,” she added.

In addition to addressing antitransgender legislation, medical systems and insurance providers need to decrease barriers and expand access to gender-affirming care, the researchers wrote.

Multipronged approach to care

In a related editorial, Brett Dolotina, BS, of the department of psychiatry at Massachusetts General Hospital and The Fenway Institute, and Jack L. Turban, MD, MHS, a fellow in psychiatry and behavioral science at the University of Stanford, discussed the need for a multipronged approach to address mental health disparities among transgender and gender-diverse youth.

While gender-affirming care was found to decrease the likelihood of suicidality and depression among this population, “medical intervention alone is not sufficient in addressing [transgender and gender-diverse] youth mental health disparities,” they wrote.

Other steps should include the implementation of evidence-based experiential learning programs into medical education to properly train physicians on how to treat these youths.

Proposed antitransgender legislation will likely have a negative impact on the mental health of transgender and gender-diverse youth and would prohibit their ability to use public facilities that match their gender, Dolotina and Turban wrote.

“It is particularly important to highlight that legislation targeting sexual and gender minority youth appears to have impacts beyond the direct impact of the legislation,” they added. “Even if antitransgender bills fail to pass, the recent discussions around them still serve to increase stigmatization of [transgender and nonbinary] youth, which is expected to worsen mental health.”

References:

Dolotina B, Turban JL. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.0926.

Governor Abbott directs DFPS to investigate gender-transitioning procedures as child abuse. https://gov.texas.gov/news/post/governor-abbott-directs-dfps-to-investigate-gender-transitioning-procedures-as-child-abuse. Accessed Feb. 25, 2022.

HB 1557/SB 1834: harming LGBTQ+ youth and censoring discussions related to sexual orientation and gender identity in schools. https://www.aclufl.org/en/legislation/hb-1557-sb-1834-harming-lgbtq-youth-and-censoring-discussions-related-sexual-orientation. Accessed Feb. 24, 2022.

Internists object to policies that interfere in patient-physician relationship and penalize evidence-based care. http://r.mail.acpnews.org/mk/mr/2tpx2J7087ysYBGedDSg-ZWb9oHBoWj_IAV3DIwx_UCDcZtFzj5yMyMlTCF6YoZ3QEwNwdHLpb3KSAycaiw3vTTHmnSOHVlQYRm_wyHtqY-6CsqBJ_GIMeWKlcSQp7kFbzawi48. Published Feb. 24, 2022. Accessed Feb. 24, 2022.

Texas governor calls on citizens to report parents of transgender kids for abuse. https://www.nbcnews.com/nbc-out/out-politics-and-policy/texas-governor-calls-citizens-report-parents-transgender-kids-abuse-rcna17455. Published Feb. 23, 2022. Accessed Feb. 24, 2022.

Tordoff DM, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.0978.