Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study

Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study

Published in: American Journal of Psychiatry. October 4, 2019. Authors: Richard Bränström, Ph.D., John E Pachankis, Ph.D.

Yet another study documenting what we already know: transgender people who receive affirming care show dramatic improvement, especially when compared to those in disaffirming environments.

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“Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98).”

The AusPATH [Australian Professional Association for Trans Health] Position Statement on "Rapid Onset Gender Dysphoria" (ROGD)

Published September 30, 2019. Shared here in its’ entirety.

“The Australian Professional Association for Trans Health (AusPATH) was established in 2009 and is Australia’s peak body for professionals involved in the health, rights and well-being of trans, including gender diverse and non-binary (TGDNB), people. The AusPATH membership comprises approximately 250 experienced professionals working across Australia.

“The term “Rapid Onset Gender Dysphoria (ROGD)” is not a diagnosis or health condition recognised by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, “ROGD” is an acronym describing a proposed phenomenon, with insufficient peer-reviewed scientific evidence to support its implementation and/or use within clinical, community, social and legal settings1.

“AusPATH affirms the rigorous processes by which diagnoses are developed and applied. These academic and clinical processes operate within professional medical organisations, and are developed by expert working groups of  scientists, clinicians, and stakeholders over long periods of time, with high levels of scientific scrutiny of the evidence-based literature. “ROGD” does not meet this standard, and therefore is not recognised by AusPATH.

“Whilst many have a clear picture of their gender from a very early age, for others the journey towards understanding their gender is more prolonged. The timing of when an individual discloses their gender to others is a separate consideration and does not necessarily reflect the development of their experienced gender. Many do not disclose their identity, rather hiding it for fear of negative reactions from others, including family rejection, discrimination, stigmatisation and social exclusion. The term “Rapid Onset Gender Dysphoria” is not, and has never been, a diagnosis or health condition but has been used in a single report describing parental perception of their adolescent’s gender identity without exploration of the gender identity and experiences of the adolescents themselves.

“AusPATH encourages continued scientific exploration within a culture of academic freedom, not censorship. All TGDNB people are deserving of gender-affirmative, evidence-based care that is underpinned by contemporary, adequately endorsed and community engaged standards of care and clinical guidelines.

“AusPATH recognises the harms caused by conversion, reparative and aversion treatments and opposes any such efforts to invalidate an individual’s experienced gender. AusPATH supports affirmative responses to young people whereby self-reported gender is respected, and young people are able to safely explore their gender and expression without judgment, pathologisation or predetermined outcome. AusPATH urges caution in the use of any term that has the potential to invalidate a person’s gender.

  1. WPATH (World Professional Association for Transgender Health) position on “Rapid-Onset Gender Dysphoria (ROGD)”4 September 2018

Counterpoint: Pediatric gender care is safe and necessary

While not research, this is a well written piece, concisely outlining the issues and why evidence-based, affirmative care for trans and gender nonbinary youth is safe and effective, and the current standard of care.

Published in: Star Tribune. June 25, 2019. Authors: KATHLEEN MILLER , MARLA EISENBERG , AMY GOWER AND G. NIC RIDER.

"Transgender and nonbinary youths experience persistent and significant distress when forced to conform to the gender they were assigned at birth. They face substantial health disparities, with higher rates of depression, suicide attempts, substance use, bullying and unprotected sexual encounters than their cisgender (i.e., not transgender) peers. However, research shows that these health outcomes are related to stigma, rather than the simple fact of being transgender or nonbinary. This is a subtle, but critical, distinction: Negative health outcomes are not intrinsic to being trans and nonbinary. Rather, daily experiences of discrimination and harassment lead to poor health outcomes..."

"The medical and research community supports gender affirming medical care as a powerful tool to improve the lives of children and adolescents who are transgender or nonbinary. There is ample and growing evidence that children and adolescents have better health outcomes when they are supported in their gender, which includes access to medical interventions when appropriate. As clinicians and pediatric researchers, we firmly support expanding access to gender affirming care for youth."

Don Cheadle Makes Powerful Fashion Statements On ‘SNL’

The Gender Dysphoria Affirmative Working Group would like to thank Saturday Night Live and actor Don Cheadle for their clear and visible statement in support of trans and gender nonbinary youth... some of the most vulnerable in our world today.

Don Cheadle Makes Powerful Fashion Statements On ‘SNL’

The award-winning actor offers support for transgender kids and takes a slap at Donald Trump.


By Carla Baranauckas

“Award-winning actor Don Cheadle had more than laughs on his mind when he hosted “Saturday Night Live” this weekend. And he made that clear with some of his wardrobe choices.”

“When he introduced Gary Clark Jr., the show’s musical guest, Cheadle wore a T-shirt that said, “Protect Trans Kids.” “

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents 

The 2018 Australian SOC for Trans and Gender Diverse Children and Adults... a very strongly affirming document based on the latest research making clear that affirmative treatment approaches - in which the youth's identity is respected and supported, where the youth are provided the freedom and safety to explore their gender without judgment - yield much happier and better adjusted youth and young adults. It also makes clear that disaffirming approaches are unethical and may cause harm.

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents 

Authors: M.M. Telfer, M.A. Tollit, C.C. Pace, & K.C. Pang.   2018.  

“Being trans or gender diverse is now largely viewed as part of the natural spectrum of human diversity. It is, however, frequently accompanied by significant gender dysphoria (GD), which is characterised by the distress that arises from incongruence between a person’s gender identity and their sex assigned at birth. It is well recognised that trans and gender diverse individuals are at increased risk of harm because of discrimination, social exclusion, bullying, physical assault and even homicide. Serious psychiatric morbidity is seen in children and adolescents. A study of the mental health of trans young people living in Australia found very high rates of ever being diagnosed with depression (74.6%), anxiety (72.2%), post-traumatic stress disorder (25.1%), a personality disorder (20.1%), psychosis (16.2%) or an eating disorder (22.7%). Furthermore 79.7% reported ever self-harming and 48.1% ever attempting suicide.”


“Increasing evidence demonstrates that with supportive, gender affirming care during childhood and adolescence, harms can be ameliorated and mental health and wellbeing outcomes can be significantly improved.”


“Understanding and using a person’s preferred name and pronouns is vital to the provision of affirming and respectful care of trans children and adolescents.  Providing an environment that demonstrates inclusiveness and respect for diversity is essential... Some children or adolescents may request use of a preferred name or pronoun only in certain circumstances, such as when their parents are, or are not, present in the room. This is important to respect and enact to enable optimal patient-clinician engagement, and ensure confidentiality and patient safety.”


“Avoiding harm is an important ethical consideration for health professionals when considering different options for medical and surgical intervention. Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.” 


“In the past, psychological practices attempting to change a person’s gender identity to be more aligned with their sex assigned at birth were used.  Such practices, typically known as conversion or reparative therapies, lack efficacy, are considered unethical and may cause lasting damage to a child or adolescent’s social and emotional health and wellbeing.”


Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth

Even something as “simple” as using a trans youth’s chosen/preferred/self-identified name can be a very powerful intervention with clear positive outcomes. And don’t we want our youth to have less depression, anxiety, and suicidal ideation?

Published in: Journal of Adolescent Health. October, 2018. Authors: Stephen T. Russell, Amanda M. Pollitt, Gu Li, Arnold H. Grossman.

“Transgender youth whose gender expression and names do not appear to match may be vulnerable to unintended disclosure or “outing,” and to discrimination or victimization, factors that could lead to mental health problems [1]. The purpose of the current study was to examine the relation between chosen name use, as a proxy for youths' gender affirmation in various contexts, and mental health among transgender youth.”

“We asked transgender youth whether they had a preferred name different from the name they were given at birth, and, if yes, asked, ‘are you able to go by your preferred name’ at home (n = 54), at school (n = 57), at work (n = 50), or with friends (n=69).”

“…chosen name use in more contexts predicted fewer depressive symptoms and less suicidal ideation and suicidal behavior. An increase by one context in which a chosen name could be used predicted a 5.37-unit decrease in depressive symptoms, a 29% decrease in suicidal ideation, and a 56% decrease in suicidal behavior. We observed similar results when we individually tested specific contexts for chosen name use (except that chosen name use with friends did not significantly predict mental health after adjusting for demographics and close friend support). Depressive symptoms, suicidal ideation, and suicidal behavior were at the lowest levels when chosen names could be used in all four contexts.”

Suicide risk in the UK Trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt

Published in: Mental Health Review Journal. · December 2014.  Authors: Louis Bailey, Jay McNeil, Sonja J. Ellis.

“The findings reported here indicate that there are extremely high rates of suicidal ideation and suicide attempt within this non-random sample of the UK trans population. However, gender transition – for those that wanted it – was shown to drastically reduce instances of suicidal ideation and suicide attempt, highlighting the important role played by social transition and gender reassignment in improving quality of life and overall well-being amongst respondents…”

“A key finding to emerge from the study was the importance of timely access to gender reassignment treatment for those who required it. Transition was shown to have a positive impact on trans people’s mental health and well-being; the processes of gender reassignment and social transition serving to significantly reduce rates of suicidal ideation and suicide attempt. The majority of participants cited the significant benefits of gender reassignment in terms of aligning their physical body with their internal sense of self, and the knock-on effects of being recognised as the gender that they felt themselves to be…”

“Despite the clear advantages of gender reassignment, some respondents reported significant issues whilst trying to obtain treatment. As has been reported elsewhere, funding delays or refusals were common within this sample and respondents alluded to having gender reassignment treatment stopped or postponed altogether. These issues may, in some cases, contribute to suicide risk within this population…”

“It is crucial that those experiencing gender dysphoria have access to gender reassignment treatment with minimal delays or disruption and that they receive relevant information and support both from medical professionals as well as more informal sources – such as family, friends and support organisations – in order to build resilience and bolster health and well-being during this particularly difficult time.”

The role of gender affirmation in psychological well-being among transgender women

No surprise that validating someone’s sense of self decreases depression and improves self esteem.

Published in: Psychology of Sexual Orientation and Gender Diversity. September 2016. Authors Tiffany R. Glynn, Kristi E. Gamarel, Christopher W. Kahler, Mariko Iwamoto, Don Operario, Tooru Nemoto.

“… we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem... Findings support the need for accessible and affordable transitioning resources for transgender women in order to promote better quality of life among an already vulnerable population.”

The Needs of Gender-Variant Children and Their Parents According to Health Professionals

Another article outlining that more supportive, nurturing, and affirming perspectives on a youth’s self-reported gender identity are needed to support both the youth and their parents.


Published in: International Journal of Transgenderism.  March 4, 2013.  Authors: Elizabeth Anne Riley, Gomathi Sitharthan, Lindy Clemson & Milton Diamond

“The issues that gender-variant children face highlight consistent deficits and negativity in the children’s lives and focus our attention to the extraordinary burden placed on gender-variant children in their formative years. A report by Grant et al. (2010) describes in detail the extraordinary levels of harassment, physical assault, and sexual violence experienced by transgender children in years during primary and high school. These issues, if unable to be alleviated, are likely to present ongoing and accumulative difficulties that then impact their lives as adults.”

“… The needs of parents overwhelmingly feature the various types of support that would help parents become informed, be able to cope, and make the best decisions for their child. Societal and community support appear to be crucial factors for parents to comfortably engage with the tasks required of them to support their child.”

“… The needs of gender-variant children identified from the professionals’ responses revealed a lack of respect for the rights of children who experience gender variance. The most frequently mentioned needs were to be accepted and supported; to be heard, respected, and loved; to have professional support and recognition; to be allowed to express their gender; to feel safe and protected; to live a normal life; to have peer contact; to have school support and; to have access to puberty-delaying hormones. The needs of the parents focused primarily on areas of support and professional assistance, namely, the need for emotional support and guidance; education and information; support from society, local community, friends, and family; competent knowledgeable professionals; diagnosis, treatment, and beneficial outcomes for their children; peer support; support, understanding, and acceptance from schools; and research.”

“Together, these findings call for education programs to provide knowledge and exposure to the issues that transgender people face, across such sectors as medicine, mental health, and teaching in schools. The targeted education of medical and counseling professionals, the inclusion of printed materials in doctors’ surgeries, and the distribution of best practice guidelines and training in schools would signal a major change across the professional and community sectors that the needs of transgender children are being taken seriously.”

Social Support Networks for LGBT Young Adults: Low Cost Strategies for Positive Adjustment

A study demonstrating that family support is essential in the wellbeing of LGBTQ+ youth.

Published in: Family Relations.  July, 2015.  Authors: Shannon D. Snapp, Ryan J. Watson, Stephen T. Russell, Rafael M. Diaz, Caitlin Ryan.

“Our study adds to the growing body of evidence that family support, both general and sexuality specific, is a crucial factor in LGBT youth’s health and well-being…”

“Two variables were most relevant in predicting adjustment: (a) the percentage of friends who knew about participants’ sexual or gender identity and (b) support related to being LGBT from friends. The presence of a network of friends to whom youth can be out has been linked to measures of health and well-being…”

“Although friendship support is clearly associated with positive well-being in young adulthood, it appears that family acceptance has a stronger overall influence when other forms of support are considered jointly.”

Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population

Family and peer support, key components of affirmative approaches for gender variant youth, are all protective factors. This study also clearly refutes the notion among some proponents of "Rapid Onset Gender Dysphoria" that disaffirming approaches and limiting access to peers is beneficial. 

Published in: American Journal of Public Health.  May, 2013. Authors: Walter O. Bockting, PhD, Michael H. Miner, PhD, Rebecca E. Swinburne Romine, PhD, Autumn Hamilton, HSD, and Eli Coleman, PhD.

 “… family support, peer support, and identity pride all were negatively associated with psychological distress, confirming that these assets are protective factors. Moreover, peer support significantly moderated the relationship between enacted stigma and psychological distress, thus emerging as a demonstrated factor of resilience in the face of actual experiences of discrimination. Only at high (but not low or medium) levels of peer support was enacted stigma not associated with psychological distress, which suggests that the negative impact of enacted stigma on mental health is pervasive and that regular contact with peers is necessary to ameliorate it.”

“Together, these results offer support for the value of transgender individuals connecting with similar others, possibly providing the opportunity to question stigma from the majority culture and reappraise their experiences in a self-affirmative way, which is consistent with what has been postulated and observed among gay and lesbian individuals. This finding is particularly pertinent because previous research found that transgender people have higher levels of depression and lower levels of peer and family support than their gay, lesbian, and bisexual counterparts. These results support a need to promote resilience by facilitating ample peer support.”

Surviving a Gender Variant Childhood: The Views of Transgender Adults on the Needs of Gender Variant Children and Their Parents

Published in: Journal of Sex & Marital Therapy. 2012. Authors: Elizabeth Anne Riley, Lindy Clemson, Gomathi Sitharthan, Milton Diamond.

“… the needs of children that emerged were most notably, for parents, school staff and other authority figures to be educated so that children do not need to ‘hide’ themselves and their gender expression for fear of adversity. The participants also expressed their need as children to be able to speak about their feelings, to have their gender expression accepted, to be recognised, to be protected, to be given the opportunity to know others with similar feelings and for their parents to be open-minded, able and willing to accept their gender variant children. This study identified that the participants’ parents primarily needed access to information and educated professionals, particularly in schools, counselling and medical contexts. Exposure to successful transgender people and access to parent support groups was also seen as a need to help parents become more accepting of their children's diversity. The need for family and wider support was mentioned as a need for both the gender variant children and the parents as some participants felt that even though support of their parents was necessary, it was not enough for them to live happily and safely within the broader society.”

“The need for ‘health literacy’ was highlighted as tool to empower individuals, in this case, parents, to respond effectively in addressing the issues with regard to their gender variant children. In particular, allowing confidence to approach professionals for support with their own and their child's emotional, physical and social well-being….”

“… it appears that living in a society where punishment is customary for lack of conformity to gender stereotypes creates a lifelong struggle and sometimes ‘withdrawal’ that caused some participants great distress and impacts on their self-esteem and ability to thrive.”

Mental Health and Self-Worth in Socially Transitioned Transgender Youth

Socially transitioned youth do better than those who do not transition, and do not show higher level of depression or anxiety than their peers or siblings.

Published in the Journal of the American Academy of Child and Adolescent Psychiatry. February 10, 2017. Authors: Lily Durwood, Katie A. McLaughlin, Kristina R. Olson.

“We found remarkably good mental health outcomes in socially transitioned transgender children in the present study. Transgender children reported normative rates of depression and slightly increased rates of anxiety. Rates of depression in transgender children did not differ significantly from those in siblings of transgender children or from those in age- and gender-matched controls, although rates of anxiety were marginally higher. Parents’ reports of their children’s depression and anxiety largely mirrored the children’s reports, although parents of transgender children reported slightly higher anxiety in their children than the children did…”

“Our findings of normative levels of depression, slightly higher rates of anxiety, and high self-worth in socially transitioned transgender children stand in marked contrast with previous work with gender-nonconforming children who had not socially transitioned. Those studies overwhelmingly reported markedly higher rates of anxiety and depression and lower self-worth, with disproportionate numbers of children in the clinical range.”

High School Gay-Straight Alliances (GSAs) and Young Adult Well-Being: An Examination of GSA Presence, Participation, and Perceived Effectiveness

Yet one more study outlining the importance of LGBTQ+ youth having the opportunity to associate with each other. Rather than making youth LGBTQ+ through ‘social contagion’, contact with other LGBTQ+ youth is protective and aids with development and health.

Published in: Applied Developmental Science. 2011. Authors: Russell B. Toomey, Caitlin Ryan, Rafael M. Diaz & Stephen T. Russell.

“… there appear to be positive associations between GSAs and well-being and educational attainment. Our finding that students who were in schools with GSAs were more likely to obtain a college education underscores the potential impact on educational achievement and socioeconomic and occupational status as an adult. In addition, given the heightened attention to suicides of young males who were known or perceived to be gay and bisexual that have been linked to anti-gay harassment at school (e.g., Katz, 2010), our findings point to GSAs as a potential context for reducing this risk – at least at low levels of LGBT school victimization - given the significant interaction between GSA participation and LGBT school victimization on lifetime suicide attempts.”

“In sum, our findings suggest that school administrators and personnel should be supportive in helping students to form and facilitate GSAs in schools as a potential source of promoting positive development for this underserved population. “

Access to GSAs Yields Happier, Better Adjusted Youth...

Contrary to current research, proponents of “Rapid Onset Gender Dysphoria” have argued that the trans identity in some youth could possibly be due to “social contagion” (ie being around youth who identify as trans and taking on the identity themselves though it is not authentic) and thereby urge parents be cautious when around allowing trans youth access to their peers via friends, GSAs, and online resources, so as to limit their exposure to the “contagion”.

There is extensive literature to document that social supports - these same friends, GSAs, and online resources - actually improve the lives and outcomes for these youth. Below is a piece from the publication of the American Federation of Teachers.

Gay-Straight Alliances

Promoting Student Resilience and Safer School Climates

Published in: American Educator. Winter 2016-2017. Author: V. Paul Poteat.

“Students in schools with GSAs report lower mental and physical health concerns, greater overall well-being, less drug use, less truancy, and greater perceived school safety than students in schools without GSAs. These findings now have been documented across a range of studies at local and national levels. Other studies have recorded feedback from GSA members who attribute instances of personal growth and empowerment, as well as a range of other positive experiences, to their GSA involvement.”

Trans Youth: Digging Beneath the Surface: Factors That Facilitate Or Impede Trans Youth Well-being in Quebec

“Quebec has one of the leading identity-affirming clinics for trans kids, the Gender Variance Clinic of the Mon- treal Children’s Hospital. This fact sheet aims at presenting oppressive factors and structures that negatively influence the well-being of trans youth as well as aspects that contribute to it…”

  • “Experiences and Dynamics in the Healthcare System: Healthcare system is a primary contributor to participants’ well-being (gender specific or general care), yet, resources in this system are not trans affirmative. Indeed, because of their gender identity, even when the services they are seeking are not transition-related, barriers to access and fear of negative treatment from healthcare professionals are an issue…”

  • “Other Institutional Spaces: Schools, Child Protection Services, Justice System - Participants feel that those institutions are positive in their lives as long as they are affirming of their identity…”

  • “Family relations and Other Social circles: Family support, in the form of feeling loved, accepted, and supported by immediate and extended family, is a significant resource to help participants cope with difficulties in other spheres of their lives. However, family can also be a source of fear and anxiety (when being rejected, or kicked out). Explicit lack of parental support is detrimental to participants’ well-being…” 

  • “Community spaces: Trans youth identified trans and LGBTQ+ non-governmental organizations (NGOs), support agencies, and other community spaces as an important source of support and information (student unions for example). Online spaces (social medias and web) were also identified as important to affirm their identity…”

Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.

Published By: The American Academy of Pediatrics. September 17, 2018.

“Supportive involvement of parents and family is associated with better mental and physical health outcomes. Gender affirmation among adolescents with gender dysphoria often reduces the emphasis on gender in their lives, allowing them to attend to other developmental tasks, such as academic success, relationship building, and future-oriented planning. Most protocols for gender-affirming interventions incorporate World Professional Association of Transgender Health and Endocrine Society recommendations and include ≥1 of the following elements:

“Social Affirmation: This is a reversible intervention in which children and adolescents express partially or completely in their asserted gender identity by adapting hairstyle, clothing, pronouns, name, etc. Children who identify as transgender and socially affirm and are supported in their asserted gender show no increase in depression and only minimal (clinically insignificant) increases in anxiety compared with age-matched averages…

“Legal Affirmation: Elements of a social affirmation, such as a name and gender marker, become official on legal documents, such as birth certificates, passports, identification cards, school documents, etc…

“Medical Affirmation: This is the process of using cross-sex hormones to allow adolescents who have initiated puberty to develop secondary sex characteristics of the opposite biological sex…

“Surgical Affirmation: Surgical approaches may be used to feminize or masculinize features… These changes are irreversible. Although current protocols typically reserve surgical interventions for adults, they are occasionally pursued during adolescence on a case-by-case basis, considering the necessity and benefit to the adolescent’s overall health…”…/09/13/peds.2018-2162

Analysis finds strong consensus on effectiveness of gender transition treatment

Published in: Cornell Chronicle. April 9, 2018

"Of 56 peer-reviewed studies, 52 (93 percent) found that gender transition improves the overall well-being of transgender people. The other 7 percent reported mixed or null findings. None of the reviewed studies showed that gender transition harms well-being."

"The positive outcomes of gender transition and related medical treatments include improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidal tendencies and substance use."

"The positive impact of gender transition has grown considerably in recent years, as surgical techniques and social support have improved."

"Regrets following gender transition are extremely rare and have become increasingly rarer."