Examining gender-specific mental health risks after gender-affirming surgery: a national database study

Abstract

Background

Transgender individuals face heightened psychological distress, including depression, anxiety, and suicidal ideation, partly due to stigma and lack of gender affirmation.

Aim

To evaluate mental health outcomes in transgender individuals with gender dysphoria who have undergone gender-affirming surgery, stratified by gender and time since surgery.

Methods

This retrospective study utilized the TriNetX database, analyzing U.S. patients aged ≥18 with gender dysphoria (International Classification of Diseases, Tenth Revision [ICD-10] F64) between June 2014 and June 2024. Six cohorts were created based on gender and surgery status: Cohorts A-D included patients with or without surgery, and Cohorts E-F allowed for gender comparison among those with surgery. Propensity score matching controlled for age, race, and ethnicity. Mental health outcomes included depression, anxiety, suicidal ideation, substance use disorder, and body dysmorphic disorder, assessed over two years post-surgery using clinician-verified ICD-10 codes. Body dysmorphic disorder (BDD) was analyzed separately and not conflated with gender dysphoria cohorts to ensure the distinction between these conditions. Statistical analysis employed risk ratios, with P < 0.05 deemed significant.

Outcomes

Primary outcomes were differences in mental health disorders, specifically depression, anxiety, suicidal ideation, body-dysmorphic disorder, and substance use disorder, among transgender individuals’ post-surgery.

Results

From 107 583 patients, matched cohorts demonstrated that those undergoing surgery were at significantly higher risk for depression, anxiety, suicidal ideation, and substance use disorders than those without surgery. Males with surgery showed a higher prevalence of depression (25.4% vs. 11.5%, RR 2.203, P < 0.0001) and anxiety (12.8% vs. 2.6%, RR 4.882, P < 0.0001). Females exhibited similar trends, with elevated depression (22.9% vs. 14.6%, RR 1.563, P < 0.0001) and anxiety (10.5% vs. 7.1%, RR 1.478, P < 0.0001). Feminizing individuals demonstrated particularly high risk for depression (RR 1.783, P = 0.0298) and substance use disorders (RR 1.284, P < 0.0001).

Clinical implications

Findings suggest the necessity for gender-sensitive mental health support following gender-affirming surgery to address post-surgical psychological risks.

Strengths and Limitations

By leveraging ICD-10 codes, we provide a more accurate representation of patient demographics and clinical outcomes, minimizing recall and reporting biases that often limit survey-based research. Limitations include the inability to account for unmeasured confounders such as social support.

Conclusion

Gender-affirming surgery, while beneficial in affirming gender identity, is associated with increased risk of mental health issues, underscoring the need for ongoing, gender-sensitive mental health support for transgender individuals’ post-surgery.