“We should expand gender-based care, not limit it,” said the report’s lead author.
Trans people who have access to gender-affirming surgery report better mental health outcomes, according to a new study.
The report, published on Wednesday in JAMA Surgery, compared the levels of psychological distress, risk of suicide and substance use in trans and diverse gender people who underwent gender-affirming surgery with those who wanted such procedures, but have not yet done so.
The researchers found that individuals who had not received the surgical interventions they wanted were almost twice as likely to report severe psychological distress and suicidal thoughts, and reported higher incidences of alcohol abuse and tobacco use as well.
“This study adds to a growing body of evidence showing that assertion in all forms can save lives for transgender and diverse gender people,” said lead author Anthony Almazan, a fourth-year medical student at Harvard Medical School. “Policies that limit access to care can put lives at risk. Our evidence shows that we must expand gender-based care, not limit it. “
Depending on the sex of the individual assigned at birth, a variety of surgical options are available, including facial contouring, tracheal scraping, chest construction, hysterectomy, phalloplasty and vaginoplasty.
Of the participants who indicated interest in one or more procedures, 13 percent had undergone surgery at least two years before being interviewed, while 59 percent wanted to, but did not.
Overall, gender-affirming surgery was associated with a 42 percent reduction in psychological distress, a 44 percent reduction in suicidal thoughts and a 35 percent reduction in smoking.
The authors say that their findings should not be interpreted as a suggestion that all trans people want or need surgery.
“There are a lot of gender-affirmation surgeries, and not everyone is looking for all options, or any other,” said senior author, Dr. Alex Keuroghlian, who runs the National Center for LGBTQIA + Health Education at the Fenway Institute in Boston. “We cannot make assumptions.”
Almazan, who plans to specialize in psychiatry, agreed, saying that undergoing any form of transition is “a personal decision”.
“The role of doctors and surgeons is to help individuals determine what is appropriate for them,” he added. “There are several studies that show that other forms of transition have had similar results.”
Keuroghlian cited a 2020 study that found that changing a person’s legal name and gender brand in government documents was also associated with improved mental health.
The new report, however, represents the first large-scale controlled study of the relationship between gender-affirming surgery and psychological well-being. It uses data from nearly 20,000 participants in the 2015 US Transgender Survey, conducted by the National Center for Transgender Equality.
About 39 percent of participants identified themselves as transgender women, 33 percent as trans men and 27 percent as non-binary. Other forms of affirmative care have been adjusted – including puberty blockers and hormone therapy – as well as sociodemographic factors, such as age, race and economic status.
The analysis did not analyze the results by specific procedure or gender identity, but Almazan indicated that this could be addressed in future studies.
Although the number of trans individuals seeking surgical transition has steadily increased in the past decade, research on its impact has been limited.
A 2019 report by the American Journal of Psychiatry found “no advantage” in surgery over psychological distress and suicide attempts. But, according to Almazan, it had a much smaller sample size and an adequate control group was lacking.
“When they updated their analysis to include a control group, they did not differentiate between people who wanted gender-affirming surgery and had not done it and those who didn’t,” he said.
Keuroghlian said that the issue of gender-based health care is often obscured by “an anti-trans political agenda” that argues that trans people “will eventually regret access to care”.
A report by the Fenway Institute last month found that most people who deteriorate, or return to their assigned sex at birth, are not motivated by internal factors. They are “fueled by social pressure, stigma, economic status, incarceration and other external factors,” said Keuroghlian.
Treatment for gender dysphoria, including surgery, is recognized as medically necessary by the American Medical Association and the World Professional Association for Transgender Health. And the Affordable Care Act prohibits insurers from explicitly excluding care related to transition.
Still, more than half of transgender people reported denying coverage for gender-claim surgery, according to a 2015 National Center for Transgender Equality survey. Only 24 states explicitly require private insurers to cover gender-claim treatment , according to the Transgender Legal Defense and Education Fund. Eight states have explicit Medicaid exclusions for transition-related coverage.
Dr. Sherman Leis, a Pennsylvania physician who has been performing gender-confirming surgeries for over 20 years, said Almazan and Keuroghlian’s findings are further proof that “all barriers to transgender care and denial of coverage insurance policies for transgender surgeries must clearly be removed. “
“This is evidence to show health insurers that they did not want to cover transgender surgery because they wanted ‘more evidence showing the effectiveness of surgery’, that gender-affirming surgery should be made available to transsexuals and people of different genders” , Laws said.