Mental Health Outcomes and Receipt of Gender-affirming Care

Background: Transgender and non-binary (TNB) youth are disproportionately burdened by mental health outcomes including increased rates of depression, anxiety, suicidal ideation/attempts. Gender-affirming care is associated with reduced long-term adverse mental health outcomes among TNB youth and is associated with a reduced lifetime incidence of suicidal ideation in TNB adults who started medical transition during adolescence. Conversely, TNB youth who present to medical care later in adolescence tend to have more adverse mental health outcomes compared with those who access earlier. Less is known about how gender-affirming care affects mental health in the short-term. We aimed to investigate changes in mental health outcomes among TNB adolescents over the first 12 months of care in an urban multidisciplinary gender clinic. We also sought to understand associations between initiation of pubertal blockers (PB) and gender-affirming hormones (GAH) with changes in mental health outcomes.

Methods: Seattle Children’s Gender Clinic (SCGC) serves a four-state area. We recruited TNB patients who completed a phone intake and in-person appointment between August 2017 and June 2018 at SCGC (N=104). We assessed three internalizing mental health outcomes: depression (Patient Health Questionnaire 9-item scale; PHQ-9, generalized anxiety (Generalized Anxiety Disorder 7-item scale; GAD-7), and suicidality (binary outcome measure based on the suicidality measure from the PHQ9) at baseline, 3, 6, and 12 month follow-up surveys. . Outcomes of interest were dichotomized into measures of moderate or severe depression and anxiety (PHQ-9 and GAD-7 scores ≥10). A priori, we considered several sociodemographic and other covariates hypothesized to potentially be associated with our outcomes of interest based on theory and prior research. We used generalized estimating equations (GEE) models to estimate the association between receipt of GAH or PB, modeled as a time-varying exposure, and mental health outcomes after adjusting for temporal trends.

Results: The cohort included 63 (60.6%) youth who identified as transgender male or male, 27 (26.0%) as transgender female or female, 10 (9.6%) as non-binary, and 4 (3.8%) responded “I don’t know” or did not respond. At baseline, 56.7% had moderate to severe depression, 50.0% moderate to severe anxiety, and 43.3% had reported self-harm/suicidal thoughts in the past 2 weeks. After adjusting for temporal trends and baseline covariates we observed a 60% decrease in depression (aOR 0.40; 95% CI: 0.17-0.95) and a 73% decrease in suicidality (aOR 0.27; 95% CI: 0.11-0.65) associated with receipt of GAH and PB. There were no changes in anxiety noted at each of the time points evaluated.

Conclusion: Gender affirming medical interventions were associated with substantial improvement in both depression and suicidality (but no anxiety) over the 12 month period. Given this population's high rates of adverse mental health outcomes, including suicidality, this data provides critical evidence that expansion of access to gender affirming care will save lives.