Editor’s Note: This activity was based from an original population study (Am J Psychiatry) Oct 4, 2019 entitled, “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study”. It has since been found to have analysis errors and a revision to the article was issued by the Am J Psychiatry on August 1, 2020.

The study originally concluded that "gender-affirming" surgery led to an improvement in mental health outcomes. It has since been found to have analysis errors. Subsequent data review found that there was no advantage to surgical intervention. The complete correction by the American Journal of Psychiatry can be found at https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.1778correction

Clinical Context

Transgender individuals, defined as those who experience incongruity between their sex assigned at birth and their current gender identity, are at increased risk for impairing psychological distress, including suicidality. Current recommendations from professional societies are to consider gender-affirming hormone and surgical interventions for transgender individuals experiencing gender incongruence. However, the long-term effect of these interventions on mental health is mostly undetermined.

The goals of this study using the Swedish Total Population Register were to examine the prevalence of mood and anxiety disorder healthcare visits and antidepressant and anxiolytic prescriptions in 2015 as they related to gender incongruence diagnosis and gender-affirming hormone and surgical treatment.

Study Synopsis and Perspective

Transgender individuals use fewer mental health services after they receive gender-affirming surgery, new research shows.

The likelihood of receiving treatment for a mood or anxiety disorder after such surgery was reduced by 8% every year during a 10-year period.

"The results provide really strong support for providing gender-affirming surgeries for those who seek them," study investigator Richard Bränström, PhD, associate professor, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden, told Medscape Medical News.

The study was published online October 4 in the American Journal of Psychiatry.

Anxiety, Depression, Suicidality

Recent estimates indicate that from 0.4% to 1.3% of persons identify as transgender. Several studies have examined mental illness in this population, but for the most part, the sample sizes in the studies were small and the follow-up periods were short, said Dr Bränström.

The investigators assessed a larger population by accessing Swedish national registries, which record all healthcare visits across the country, said Dr Bränström.

From these registries, the investigators gathered data on mental health treatment, including healthcare visits for mood and anxiety disorders, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt.

They compared the general Swedish population with individuals diagnosed with gender incongruence (either transsexualism or gender identity disorder) between January 1, 2005, and December 31, 2015.

Of the total Swedish population of more than 9.7 million individuals, 2679 persons received a diagnosis of gender incongruence during the study period.

Adjusted analyses for sociodemographic factors showed that compared with the general population, those with gender incongruence were about 6 times more likely to have a mood disorder (9.3% vs 1.0%) or an anxiety disorder (7.4% vs 0.6%).

They were also 3 times more likely to have received prescriptions for antidepressants (28.8% vs 9.4%) and anxiolytic medications (16.8% vs 5.8%). They were more than 6 times more likely to have been hospitalized after a suicide attempt. Slightly more than 70% of individuals with gender incongruence received prescriptions for hormonal treatment. For half of those who were treated with hormones, hormone treatment was initiated within the last 5 years.

Investigators found that 38% of individuals with gender incongruence received gender-affirming surgery.

Stigmatization, Discrimination

The investigators found no link between receiving hormonal treatment and a reduction in mental health services.

However, among those who received gender-affirming surgery, treatment for mood or anxiety disorder was significantly reduced as time went on (adjusted odds ratio, 0.92; 95% confidence interval, 0.87-0.97). The likelihood of treatment for a mood or anxiety disorder was reduced by 8% for each year after the surgery.

The prevalence of mental health treatment in the study population was 45.3% before surgery and 21.1% 10 years after the surgery. Even then, the use of mental health services by transgender individuals still exceeded that of the general population, which is 12.5%.

This finding, said Dr Bränström, highlights the need to address other factors that may improve the mental health of transgender individuals. These include addressing victimization and economic inequality.

"One reason transgender people have an increased risk of mental health problems is that they break norms around gender, which exposes them to significant stigma and discrimination," said Dr Bränström.

It is unclear why surgery and not hormonal therapy was associated with a reduction in the use of mental health services, he said.

The investigators note that the study had several limitations.

"We specifically lacked information regarding gender assigned at birth, legal gender change, and gender identity at the time of data collection, preventing subgroup analyses of the transgender population," they write.

Another possible limitation is that the results may not apply outside of Sweden. They note, for example, that some US states prohibit the use of state funds to pay for gender-affirming treatments. In addition, the Veterans Health Administration prohibits gender-affirming surgery within Veterans Affairs (VA) facilities or use of VA funding for gender-affirming treatments.

Lack of coverage for gender-affirming treatments "drives the use of non–medically supervised hormones and surgeries, thereby exacerbating physical health risks and the other epidemics disproportionately borne by the global transgender population, including suicide and HIV infection," the investigators note.

Unique Study

Commenting on the findings for Medscape Medical News, Jack Drescher, MD, clinical professor of psychiatry, Columbia University, New York City, and section editor of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision, chapter on gender dysphoria, said the study was "unique" in its size and the fact that it was carried out in a country that has a national healthcare system that keeps track of medical records.

The results are "encouraging in terms of the idea that some interventions may be helpful for transgender people," said Dr Drescher.

One of the caveats of the study is that the researchers assessed records of service usage, or "what's fed into the computer system," and did not interview patients, so it does not provide "absolute proof," said Dr Drescher.

More research in this field is needed, he added.

Also commenting for Medscape Medical News, Jason D. Flatt, PhD, assistant professor, Institute for Health and Aging, University of California, San Francisco, who has carried out research on transgender issues, said he was not surprised by the study findings.

The authors "nicely" highlight some of the study limitations, including that Sweden offers free gender-affirming care and that levels of discrimination toward gender minorities may be relatively low there, said Dr Flatt.

He emphasized that staff who provide services to transgender and nonbinary patients should be trained in inclusive care. This should apply to everyone who has contact with patients, including frontline and support staff members, as well as clinicians, he said.

The study was supported by the Swedish Research Council and the Swedish Research Council for Health, Working Life, and Welfare. The study investigators and Dr Flatt have disclosed no relevant financial relationships.

Am J Psychiatry. Published online October 4, 2019.^[1]

Clinical Implications

• Transgender individuals are more likely than the general population to use mental health treatments, but gender-affirming treatments may lower this risk, based on a study using the Swedish Total Population Register.
• The longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment supports the decision to offer such procedures to transgender individuals seeking them, and it supports policies that ensure coverage for such treatment.
• Implications for the Healthcare Team: Reducing stressors to which transgender individuals are disproportionately exposed may help improve their mental health, as may ensuring access to transgender-affirming mental healthcare.

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