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ORIGINAL RESEARCH
published: 26 July 2021
doi: 10.3389/fpsyt.2021.621075
Frontiers in Psychiatry | www.frontiersin.org 1July 2021 | Volume 12 | Article 621075
Edited by:
Maiko Abel Schneider,
McMaster University, Canada
Reviewed by:
Angel L. Montejo,
University of Salamanca, Spain
Jeffrey H. D. Cornelius-White,
Missouri State University,
United States
*Correspondence:
Poli Mara Spritzer
spritzer@ufrgs.br
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 25 October 2020
Accepted: 30 June 2021
Published: 26 July 2021
Citation:
Silva ED, Fighera TM, Allgayer RM,
Lobato MIR and Spritzer PM (2021)
Physical and Sociodemographic
Features Associated With Quality of
Life Among Transgender Women and
Men Using Gender-Affirming Hormone
Therapy. Front. Psychiatry 12:621075.
doi: 10.3389/fpsyt.2021.621075
Physical and Sociodemographic
Features Associated With Quality of
Life Among Transgender Women and
Men Using Gender-Affirming
Hormone Therapy
Eliane D. Silva 1,2 , Tayane M. Fighera 1,2, Roberta M. Allgayer 1, 2, Maria Inês R. Lobato 2and
Poli Mara Spritzer 1,2,3
*
1Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,
2Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, 3Department of Physiology, Federal
University of Rio Grande do Sul, Porto Alegre, Brazil
Background: Gender dysphoria is defined as a feeling of distress resulting from the
incongruence between the sex assigned at birth and the gender identity, lasting longer
than 6 months. In individuals with gender dysphoria, gender-affirming hormone therapy
(GAHT) may improve quality of life (QoL).
Objectives: We aimed to assess perceived QoL, to compare QoL scores between trans
women and men and to identify possible contributing factors related to GAHT in a sample
of transgender women and transgender men.
Methods: In this cross-sectional study, transgender women and men were recruited
by availability sampling from a national transgender health service. Individuals over
18 years old with a confirmed diagnosis of gender dysphoria receiving medically
prescribed GAHT for at least 6 months were consecutively included. Also included
were trans men who had undergone mastectomy and trans women who had received
breast augmentation surgery. Individuals who had undergone gender affirmation surgery
(specifically genital surgery) or with uncontrolled clinical/psychiatric conditions at the time
of the initial assessment were excluded. Sociodemographic, physical, and hormone data
were collected from all participants. The WHOQOL-BREF questionnaire was used to
evaluate QoL. A total of 135 transgender individuals were invited. Seventeen individuals
with previous genital surgery (12.6%) and five who refused to participate (3.7%) were
excluded. Therefore, 113 patients were enrolled and completed the study (60 trans
women and 53 trans men).
Results: QoL scores did not differ between trans women and trans men. In
trans women, greater breast development and stable relationships, and higher
body mass index were associated with higher QoL domain scores. In trans
men, higher domain scores were found in individuals in a stable relationship,
with increased body hair, engaging in physical activity, and being employed.
Silva et al. Well-being in Transgender Individuals Using Hormones
Conclusion: Data from this study suggest that GAHT-related physical characteristics,
such as breast development in trans women and increased body hair in trans
men, are similar between groups, are associated with higher QoL scores, and that
sociodemographic parameters may impact these associations. Healthcare providers
might consider these factors when planning interventions to improve QoL in
transgender individuals.
Keywords: transgender, cross-sex hormone therapy, quality of life, gender incongruence, gender dysphoria,
gender-affirming hormone therapy
INTRODUCTION
Transgender is a term used to describe the incongruence between
the gender identity and the sex assigned at birth (1). The wish to
live and be accepted as a person of the opposite gender may be
accompanied by a feeling of inadaptation and a desire to modify
the body as much as possible into the gender identity (2) and is
often associated with distress or dysphoria.
Although derived from limited data and possibly
underestimated, the prevalence of gender incongruence has been
reported as 4.6/100,000 individuals (6.8 for trans women and 2.6
for trans men) (3). More recent data from the United States show
a prevalence of gender dysphoria of 390/100,000 individuals, or
almost 1 million adults nationally (4).
Gender-affirming hormone therapy (GAHT) is often the first
medical intervention used to relieve psychological suffering,
minimize psychiatric comorbidities, and improve quality of life
(QoL) in individuals with gender dysphoria (5). In GAHT,
sexual hormones are used for development of secondary sex
characteristics compatible with the gender identity and to reduce
clinical characteristics of the birth gender (6). Trans women
use oral or transdermal estrogen associated with antiandrogens,
while trans men use injectable or transdermal testosterone (5,
6). GAHT initiation requires careful clinical and laboratory
evaluation. Doses and administration routes vary according
to the individual response and the clinical condition of each
subject (6). The external physical changes induced by GAHT
produce positive psychological effects, increase self-confidence,
and facilitate conviviality and social interaction. In addition,
GAHT-associated changes reinforce gender affirmation and
social recognition (7–9).
According to the World Health Organization (WHO), QoL is
a broad concept, encompassing the complex interplay between
physical health, psychological status, level of independence,
social relationships, personal beliefs, and the relationship with
the environment (10–12). Individuals with gender dysphoria
are more likely than cisgender individuals to experience
discrimination, in both their personal and/or social life; this
unequal treatment has the potential to affect all aspects of life,
including the physical, psychological and well-being domains,
as well as access to services and basic human rights (13).
Previous studies report that factors such as gender affirmation
surgery (GAS) (14), family support, working or studying
(15) and body image can improve the QoL of transgender
individuals (16).
The available data are controversial when comparing QoL
between transgender individuals and the general population.
While some studies have found no differences (17,18), others
have found that transgender individuals have lower physical and
mental QoL scores compared with a control group (19,20). Also,
previous studies have shown that trans men have better QoL
scores than trans women on the physical functioning subscale
(20,21). Changes induced by testosterone therapy, including
body and facial hair growth, changes in body composition, and
voice deepening, may contribute to the satisfaction of these
individuals (6,22,23).
In addition, most QoL studies related to gender dysphoria
to date have addressed the results of gender affirmation surgery
(GAS), only a few have evaluated the impact of clinical changes
resulting from GAHT on QoL parameters. Previous data suggest
that GAHT has a positive effect on well-being (8) health in
general, self-esteem (24), anxiety, depression (25), cognitive
function (26), and QoL (15,27). Recently, a systematic review
including 7 observational studies assessed the QoL of transgender
individuals receiving GAHT who did not undergo GAS and
reported improved QoL, anxiety, and depression in transgender
individuals receiving GAHT vs. those without hormone therapy.
However, high-quality research on the impact of GAHT-related
physical changes on QoL is still needed in the transgender
population; likewise, a validated QoL instrument for the trans
population is still lacking (28).
Therefore, the aims of this study were to assess perceived QoL
in a sample of individuals with gender dysphoria before genital
surgery, to compare QoL scores between trans women and men
and to identify sociodemographic and physical characteristics
related to GAHT that can contribute to their QoL.
MATERIALS AND METHODS
Participants and Recruitment
This cross-sectional study evaluated transgender women and
men recruited by availability sampling from the outpatient
endocrine clinic of the Gender Identity Program at the
Hospital de Clínicas de Porto Alegre (HCPA), Brazil. Patients
over 18 years old with a confirmed diagnosis of gender
dysphoria receiving medically prescribed GAHT for at least
6 months were consecutively included. Also included were
trans men who had undergone mastectomy and trans women
who had received breast augmentation surgery. Individuals
who had undergone GAS (specifically genital surgery) or with
Frontiers in Psychiatry | www.frontiersin.org 2July 2021 | Volume 12 | Article 621075
Silva et al. Well-being in Transgender Individuals Using Hormones
uncontrolled clinical/psychiatric conditions at the time of the
initial assessment were excluded.
Recruitment took place over a 12-month period between
2016 and 2017. A total of 135 transgender individuals were
invited. Seventeen individuals with previous GAS (12.6%) and
five who refused to participate (3.7%) were excluded. Therefore,
113 patients were enrolled and completed the study (60 trans
women and 53 trans men).
Sociodemographic Variables and Physical
Examination
Sociodemographic and clinical data as well as hormone levels
were collected from medical records: age, schooling, occupational
status, marital status, smoking, alcohol use disorder (2), illicit
drug use, sexually transmitted infections (STIs), physical activity
levels, previous mastectomy (trans men), and presence of
breast implants (trans women). Smoking status was categorized
as current smoker, former smoker, or never smoker. Active
individuals were those engaged in moderate-intensity physical
activity for at least 150 min or in vigorous-intensity physical
activity for 75 min per week, according to the World Health
Organization (29) definition for people between 18 and 64
years of age. Individuals not meeting these criteria were
considered sedentary.
Blood pressure was measured after a 10-min rest in a sitting
position, with the feet on the floor and the arm supported at the
level of the heart, using an automatic blood pressure monitor
with an appropriate cuff for the arm diameter (Omron HEM 742,
Rio de Janeiro, Brazil). Weight was measured in kilograms (kg)
using an electronic anthropometric scale with a 100 g scale, with
a capacity of 180 kg. All individuals were weighed barefoot and
wearing an apron (Filizola Personal, São Paulo, Brazil). Height
was measured in meters (m), using a stadiometer fixed to the wall
(Tonelli E150A, Santa Catarina, Brazil). Body mass index (BMI)
was calculated as weight in kilograms divided by squared height
in meters (kg/m2) and was categorized as normal weight (18 to
<25), overweight (25 to <30), and obesity (≥30). The degree of
body hairiness was assessed using the Ferriman-Gallwey scale,
which visually attributes a score from zero (no hair) to four
to nine body areas, with scores summed to provide a total
score. Trans men were stratified according to median Ferriman-
Gallwey values into two groups: ≤or >20 (30). The Tanner
scale was used to assess the degree of breast development, with
individuals categorized into two groups (Tanner <or ≥4) (31).
Gender-Affirming Hormone Therapy
Trans women were prescribed oral estrogen (estradiol valerate,
2–4 mg/d) associated with antiandrogen (spironolactone 50–
150 mg/d or cyproterone acetate 50–100 mg/d). For trans men,
intramuscular testosterone cypionate was used (200 mg every 2–
4 weeks). Dosages were compatible with the gender identity of
individuals, and individualized according to clinical response and
laboratory parameters (6). Upon arrival at our outpatient clinic
and before a short washout period for clinical evaluation, 47
(78.3%) trans women and 19 (35.8%) trans men were already
self-medicating with different hormone treatments and dosages.
Quality of Life Assessment
QoL was assessed using a validated Brazilian Portuguese version
of the WHOQOL-BREF questionnaire (32). WHOQOL-BREF is
composed of 26 structured questions, of which two are general
questions about QoL and 24 questions represent each facet
of the WHOQOL-100, divided into four domains: physical,
psychological, social relations, and environment (32,33). The
average score in each domain indicates the individual’s perceived
satisfaction with each QoL aspect. Each individual WHOQOL-
BREF item was scored in a Likert scale from 1 (very dissatisfied
/very bad) to 5 (very satisfied/very good), resulting in final scores
on a scale of 4–20 for each domain. All scores are multiplied
by 4 to be directly comparable with scores derived from the
WHOQOL-100 (33). For interpretation purposes, all scores were
transformed into a scale from 0 to 100 to allow comparisons
between domains containing different numbers of items, as
previously reported (15,34). Higher scores (closer to 100%)
indicate a better self-perceived QoL. The WHOQOL-BREF has
been shown to be a reliable instrument for the assessment of
QoL in the general population in several countries (33,35). The
questionnaire was administered by the interviewer during an
outpatient visit scheduled after 6 months of GAHT. The answers
referred to the last 2 weeks prior to the day of data collection.
Statistical Analysis
Winpepi R
was used for sample size calculation. Sample size
was estimated based on a previous study, according to which
the chance of higher QoL in the social domain was higher
in trans men than trans women (15). Thus, considering
a power of 80% and alpha of 5%, 100 trans individuals
would be required to detect a difference of approximately
10% between WHOQOL-BREF domain scores between trans
women and trans men (15). Variables with Gaussian distribution
were assessed by the Shapiro-Wilk normality test. Continuous
variables were expressed as mean and standard deviation
and median and interquartile range for variables with non-
Gaussian distribution. Categorical variables were expressed as
frequency and percentage. Comparisons between two categories
were analyzed using Student’s t-test, and comparisons between
more than two categories were analyzed by ANOVA. The chi-
square (χ2) test was used for categorical variables. Data were
analyzed using the Statistical Package for the Social Sciences,
version 18.0 (SPSS Inc., Chicago, IL). P<0.05 were considered
statistically significant.
RESULTS
Clinical and Sociodemographic
Characteristics in Trans Women and Trans
Men
Clinical, hormonal, and sociodemographic characteristics are
shown in Table 1.
The mean age of transgender individuals was 32.5 ±9.0 years.
Most participants (75.2%) had more than 9 years of schooling,
69% were employed, and 42.5% were in a stable relationship. This
profile was similar in trans women and trans men. Mean blood
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Silva et al. Well-being in Transgender Individuals Using Hormones
TABLE 1 | Clinical, hormonal, and sociodemographic characteristics of transgender individuals.
Variable All (113) Trans women (60) Trans men (53) p
Age (years) 32.5 ±9 34.1 ±8.7 30.8 ±9.2 0.053a
Schooling—n(%)
<9 years 28 (24.8) 14 (23.3) 14 (26.4) 0.424b
>9 years 85 (75.2) 46 (76.7) 39 (73.6)
Occupation—n(%)
Employed 78 (69) 45 (75) 33 (62.3) 0.144b
Unemployed 27 (23.9) 15 (25) 12 (22.6)
Student 8 (7.1) – 8 (15.1)
Marital status—n(%)
Stable relationship 48 (42.5) 25 (41.7) 23 (43.4) 0.853b
Single 65 (57.5) 35 (58.3) 30 (56.6)
Gender-affirming hormone therapy (months) 21.81 ±8.31 22.15 ±8.57 21.43 ±8.07 0.650a
Previous hormone therapy—n(%)
Yes 66 (58.4) 47 (78.3) 19 (35.8) <0.001b
No 47 (41.6) 13 (21.7) 34 (64.2)
Physical activity—n(%)
Active 27 (23.9) 12 (20) 15 (28.3) 0.302b
Sedentary 86 (76.1) 48 (80) 38 (71.7)
BMI (kg/m2) 28 ±5.4 27 ±4.1 29 ±6.4 0.077a
18 to <30—n(%) 75 (66.4) 44 (73.3) 31 (58.5) <0.001a
≥30—n(%) 38 (33.6) 16 (26.7) 22 (41.5)
Estradiol (pmol/L) – 203 (135–331) 160 (127–254) –
Testosterone (nmol/L) – 0.92 (0.31–4.48) 16.63 (9.82–21.97)
SHBG (nmol/L) – 53 (33–90) 20 (16–30)
SBP 118.3 ±10.4 118.2 ±10.8 118.5 ±10.1 0.870a
DBP 78.7 ±7.8 79.4 ±8.5 77.9 ±6.9 0.313a
Smoking—n(%)
Yes 13 (11.5) 8 (13.3) 5 (9.4) 0.726b
No 88 (77.9) 45 (75) 43 (81.2)
Former smoker 12 (10.6) 7 (11.7) 5 (9.4)
Alcohol use disorder—n(%)
Yes 2 (1.8) 2 (3.3) – –
No 106 (93.8) 56 (93.4) 50 (94.3)
Former alcohol use disorder15 (4.4) 2 (3.3) 3 (5.7)
Illicit drug use—n(%)
Yes 2 (1.8) 2 (3.3) – –
No 108 (95.6) 56 (93.4) 52 (98.1)
Former drug use 3 (2.6) 2 (3.3) 1 (1.9)
HIV—n(%) (110)c
Reactive 13 (11.8) 13 (22.4) – –
Non-reactive 97 (88.2) 45 (77.6) 52 (100)
HCV—n(%) (108)c
Reactive – – – –
Non-reactive 108 (100) 56 (100) 52 (100)
HBsAg—n(%) (103)c
Reactive 1 (1) 1 (1.8) – –
Non-reactive 102 (99) 54 (98.2) 48 (100)
VDRL—n(%) (103)c
Reactive 10 (9.7) 10 (18.9) – –
Non-reactive 93 (90.3) 43 (81.1) 50 (100)
(Continued)
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Silva et al. Well-being in Transgender Individuals Using Hormones
TABLE 1 | Continued
Variable All (113) Trans women (60) Trans men (53) p
Breast surgical procedure—n(%)
Yes – 18 (30) 13 (24.5) 0.515b
No – 42 (70) 40 (75.5)
Tanner (breast)—n(%)
<4 – 29 (48.3) – –
≥4 – 31 (51.7) –
Ferriman-Gallwey—n(%)
≤20 – – 23 (43.4) –
>20 – – 30 (56.6)
BMI, body mass index (18 to <30: normal weight and overweight, ≥30: obesity); SHBG, sex hormone binding globulin; SBP, systolic blood pressure; DBP, diastolic blood pressure;
HIV, human immunodeficiency virus; HCV, hepatitis C virus; HBsAg, serology for hepatitis B; VDRL, venereal disease research laboratory for syphilis; Breast surgical procedure: breast
implants for trans women and mastectomy for trans men.
Data expressed as mean and standard deviation, median and interquartile range or frequency and percentage.
aStudent’s t-test.
bPearson’s chi-square test.
cNumber of individuals tested.
1According to DSM-5 American Psychiatric Association. Bold values indicate statistical significance.
pressure was within the reference values for normotensive adults,
and 23.9% of the individuals were considered physically active,
with no differences between the groups. Mean BMI was 28.0 ±
5.4 kg/m2, and obesity was observed in 33.6%. The rate of obesity
was higher in trans men (41.5%) than in trans women (26.7%;
p<0.001; Table 1).
The prevalence of current smoking was 11.5%, and alcohol
abuse and illicit drug use was reported by 1.8%. Thirteen
participants were HIV-positive, and 10 were VDRL-reactive—all
of them were trans women. Among HIV-positive patients, 92.0%
were using antiretroviral drugs. The percentage of trans women
who had a previous breast implant procedure was 30.0 and 24.5%
of trans men had a mastectomy (Table 1).
Regarding GAHT formulations, 47 (78.3%) trans women
were using estradiol valerate 2 mg/day, 8 (13.3%), 3 mg/day,
and 5 (8.4%), 4 mg/day. With respect to antiandrogen drugs,
18 (30.0%) were using spironolactone 50 mg/day, 32 (53.3%),
100 mg/day and 4 (6.7%), 150 mg/day; 6 (10.0%) were using
cyproterone acetate 50 mg/day. All trans men were using
intramuscular testosterone cypionate 200 mg every 2–4 weeks.
Median hormone levels were within the range for GAHT-
treated persons, and a higher proportion of trans women (78.3%)
reported previous irregular use of self-medicated hormone
therapy than trans men (35.8%). The mean duration of medically
prescribed GAHT was 21.81 ±8.31 months.
Comparisons of Perceived Quality of Life in
Trans Women and Trans Men
The scores for the WHOQOL-BREF domains were presented on
a scale of 0–100. In general, individuals had scores above 60%,
without significant differences between trans women and trans
men (Table 2).
In both groups, the lowest QoL score was recorded in the
environmental domain (trans women =59.73 ±14.61, trans men
=60.79 ±14.60), followed by the psychological and physical
domains (64 ±15.26 and 69.88 ±17.13 for trans women; 62.73
TABLE 2 | Mean WHOQOL-BREF scores in transgender individuals.
Domain All (113) Trans women (60) Trans men (53) p
Physical 68.23 ±17.85 69.88 ±17.13 66.37 ±18.62 0.300
Psychological 63.40 ±17.15 64 ±15.26 62.73 ±19.2 0.698
Social relations 69.61 ±20.94 70.13 ±18.55 69.02 ±23.53 0.779
Environment 60.23 ±14.55 59.73 ±14.61 60.79 ±14.60 0.704
Quality of life 73.23 ±17.82 75.83 ±16.57 70.28 ±18.86 0.099
Data expressed as mean and standard deviation; Domains with scores from 0 to 100.
Student’s t-test.
±19.20 and 66.37 ±18.62 for trans men, respectively). The
highest score was recorded in the social relations domain: 70.13
±18.55 for trans women and 69.02 ±23.53 for trans men. Mean
overall QoL was 75.83 ±16.57 for trans women and 70.28 ±
18.86 for trans men.
Quality of Life Scores According to
Sociodemographic and Clinical
Characteristics
Transgender Women
When comparing sociodemographic data categories and clinical
characteristics according to WHOQOL-BREF domains, the
social relations domain score was significantly higher in trans
women in a stable relationship than in single ones (76.66 ±
10.75 vs. 65.47 ±21.49; p=0.011), and in those with BMI ≥30
(78.64 ±13.25 vs. 67.04 ±19.35; p=0.031). In addition, trans
women with Tanner stage 4 or greater breast development had a
significantly higher mean physical domain score (75.49 ±13.95
vs. 64.63 ±18.35, p=0.013). No significant differences in QoL
scores were observed between trans women with and without
breast implants. Among those without breast implants, 31% had a
Tanner score ≥4. QoL scores were similar in different occupation,
education, and HIV categories (Table 3).
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Silva et al. Well-being in Transgender Individuals Using Hormones
TABLE 3 | Mean WHOQOL-BREF scores in trans women according to sociodemographic and clinical characteristics (N=60).
WHOQOL-BREF domains
Physical pPsychological pSocial relations pEnvironment pQuality of life in general p
Sociodemographic characteristics
Marital status
Single 68.97 ±17.03 0.634 62.8 ±14.81 0.307 65.47 ±21.49 0.011 60.17 ±14.44 0.786 74.28 ±14.2 0.422
Stable relationship 71.14 ±17.55 66.4 ±15.84 76.66 ±10.75 59.12 ±15.11 78.00 ±19.52
Occupation
Employed 72.38 ±14.87 0.111 65.33 ±13.95 0.244 69.62 ±18.47 0.716 61.66 ±14.12 0.070 75.55 ±14.09 0.862
Unemployed 62.38 ±21.50 60.00 ±18.61 71.66 ±19.36 53.95 ±15.00 76.66 ±23.08
Education level
<9 years 65.05 ±20.73 0.232 57.50 ±17.4 0.068 72.02 ±12.05 0.668 58.70 ±18.35 0.765 77.67 ±22.56 0.712
>9 years 71.35 ±15.85 65.97 ±14.16 69.56 ±20.20 60.05 ±13.50 75.27 ±14.55
Physical activity
Active 73.80 ±17.81 0.379 63.75 ±14.79 0.950 70.83 ±20.87 0.886 57.55 ±9.83 0.567 76.04 ±16.39 0.962
Sedentary 68.89 ±16.99 64.06 ±15.52 69.96 ±18.17 60.28 ±15.61 75.78 ±16.79
HIV
Reactive 70.32 ±18.34 0.953 68.86 ±12.77 0.221 75.00 ±17.34 0.260 61.05 ±15.28 0.760 75.96 ±17.27 0.929
Non-reactive 70.63 ±15.69 63.11 ±15.19 68.33 ±18.93 59.65 ±14.28 76.38 ±14.65
Clinical characteristics
Tanner stage
<4 64.63 ±18.35 0.013 60.80 ±16.98 0.94 68.54 ±19.21 0.497 58.36 ±14.99 0.457 72.54 ±17.5 0.117
≥4 75.49 ±13.95 67.41 ±12.57 71.83 ±18.01 61.2 ±14.3 79.31 ±15.04
Breast implants
Yes 67.6 ±17.71 0.116 62.97 ±15.73 0.118 70.83 ±19.32 0.662 58.63 ±15.33 0.374 75.59 ±16.78 0.374
Noa75.19 ±14.82 66.38 ±14.22 68.51 ±17.04 62.32 ±12.79 76.38 ±16.54
BMI
18 to <30 69.23 ±18.99 0.633 62.15 ±16.26 0.068 67.04 ±19.35 0.031 58.80 ±15.54 0.417 75.85 ±17.34 0.988
≥30 71.65 ±10.79 69.06 ±10.98 78.64 ±13.25 62.30 ±11.71 75.78 ±14.76
Data expressed as mean and standard deviation; domains with scores from 0 to 100.
aTanner ≥4 in 31%; Student’s t-test. Bold values indicate statistical significance.
Transgender Men
Significantly higher scores were observed in trans men in
a stable relationship than in single ones in the following
domains: physical (75.73 ±14.86 vs. 60.71 ±19.44; p=0.010),
psychological (69.13 ±14.35 vs. 57.83 ±21.15; p=0.032), and
social relations (75.72 ±17.57 vs. 63.88 ±26.38; p=0.049).
Also, increased body hair (Ferriman-Gallwey score >20) was
associated with higher QoL scores in the physical (71.78 ±16.81
vs. 59.31 ±18.85; p=0.014), psychological (67.83 ±15.62 vs.
56.08 ±21.63; p=0.026), and social relations domains (74.44
±18.81 vs. 61.95 ±27.38; p=0.049). Being physically active
was associated with higher physical (74.04 ±11.41 vs. 63.34 ±
20.12; p=0.019), psychological (70.66 ±17.40 vs. 59.60 ±19.18;
p=0.049), social relations (78.33 ±19.10 vs. 65.35 ±24.31; p
=0.048), and environment domain scores (70.00 ±10.21 vs.
57.15 ±14.56; p=0.003) when compared to being sedentary.
Being in a stable relationship was also associated with a higher
general WHOQOL-BREF score (76.08 ±15.46 vs. 65.83 ±20.21;
p=0.049; Table 4).
Employment was related to higher QoL scores. Students had
intermediate scores vs. the other occupation categories in the
physical (p=0.004) and psychological (p=0.010) domains.
No significant differences in QoL scores were observed
regarding prior mastectomy, BMI, and education level (Table 4).
DISCUSSION
In the present study, QoL scores were similar in trans women
and trans men receiving GAHT. Among trans women, higher
QoL scores were associated with breast development, being
in a stable relationship, and greater BMI. In trans men, QoL
was associated with increased body hair, being in a stable
relationship, being physically active, and being employed. While
a few previous studies have shown a general benefit of GAHT to
QoL in transgender individuals (15,18,24,28,36), to the best
of our knowledge this is the first study to specifically evaluate
QoL in association with GAHT-related clinical characteristics in
trans men and trans women not submitted to GAS (except for
mastectomy/breast augmentation surgery in some trans men and
women, respectively).
The mean BMI observed in trans women was 27 kg/m2.
Obese trans women had a better score in the social relations
domain when compared to trans women with normal BMI and
overweight. Recent studies have demonstrated that GAHT is
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Silva et al. Well-being in Transgender Individuals Using Hormones
TABLE 4 | Mean WHOQOL-BREF scores in trans men according to sociodemographic and clinical characteristics (N=53).
WHOQOL-BREF domains
Physical pPsychological pSocial relations pEnvironment pQuality of life in general p
Sociodemographic characteristics
Marital status
Single 60.71 ±19.44 0.010 57.83 ±21.15 0.032 63.88 ±26.38 0.049 58.85 ±15.26 0.274 65.83 ±20.21 0.049
Stable relationship 75.73 ±14.86 69.13 ±14.35 75.72 ±17.57 63.31 ±13.59 76.08 ±15.46
Occupationa
Employed 72.07 ±16.49a0.004 67.57 ±16.06a0.010 70.20 ±19.65 0.348 64.01 ±13.73 0.071 72.34 ±19.70 0.378
Unemployed 52.67 ±19.56b49.16 ±21.08b61.11 ±31.04 52.86 ±13.87 63.54 ±18.81
Student 63.39 ±15.71ab 63.12 ±20.86ab 76.04 ±25.75 59.37 ±16.10 71.87 ±14.56
Education level
<9 years 63.77 ±23.09 0.548 58.92 ±21.49 0.392 72.61 ±25.19 0.511 56.91 ±15.02 0.251 75.00 ±16.26 0.280
>9 years 67.30 ±17.00 64.10 ±18.42 67.73 ±23.11 62.17 ±14.38 68.58 ±19.63
Physical activity
Active 74.04 ±11.41 0.019 70.66 ±17.40 0.049 78.33 ±19.10 0.048 70.00 ±10.21 0.003 75.00 ±13.36 0.257
Sedentary 63.34 ±20.12 59.60 ±19.18 65.35 ±24.31 57.15 ±14.56 68.42 ±20.49
Clinical characteristics
Ferriman-Gallwey
≤20 59.31 ±18.85 0.014 56.08 ±21.63 0.026 61.95 ±27.38 0.049 58.55 ±13.82 0.335 69.02 ±19.16 0.674
>20 71.78 ±16.81 67.83 ±15.62 74.44 ±18.81 62.50 ±15.17 71.25 ±18.90
Mastectomy
Yes 69.78 ±20.34 0.453 63.07 ±24.28 0.942 73.07 ±25.03 0.480 67.06 ±11.45 0.074 75.96 ±16.50 0.215
No 65.26 ±18.71 62.62 ±17.61 67.70 ±23.20 58.75 ±15.04 68.43 ±19.04
BMI
18 to <30 70.04 ±17.70 0.089 64.83 ±19.16 0.349 70.96 ±21.06 0.481 61.89 ±14.64 0.518 71.37 ±18.31 0.623
≥30 61.20 ±19.06 59.77 ±19.30 66.28 ±26.90 59.23 ±14.73 68.75 ±19.95
Data expressed as mean and standard deviation; domains with scores from 0 to 100.
Student’s t-test.
aTwo-way ANOVA.
b,abDifferent superscript letters in each row indicate which groups differ statistically for the specific variable. Bold values indicate statistical significance.
associated with significant body fat gain and reduced muscle mass
(36,37). Indeed, a multicenter study including 179 trans women
found an increase of 42% body fat in the legs, 18% in the android
region and 34% in the gynoid region (23). Thus, it is possible that
the higher social relations score observed in our obese patients
is related to a sense of well-being produced by a more feminine
body fat distribution.
In relation to trans men, the majority in our study had BMI
values compatible with overweight or obesity. However, there
was no significant difference in the QoL scores between obese
and non-obese categories. Recent studies have shown that GAHT
for trans men is associated with increased BMI. In a systematic
review of 13 studies, we have previously detected an increase of
1.3–11.4% in BMI with the use of testosterone (38). It is likely that
this increase in BMI occurs at the expense of increased muscle
mass associated with the anabolic effect of testosterone (37).
In the present study, we observed that being in a stable
relationship was significantly associated with the social relation
domain in trans women and a better score in the physical,
psychological, social relations, and general QoL domains in trans
men, which is in agreement with other studies in the literature
(18,21,39). Motmans et al. (21) assessed 139 individuals
and observed that 52.5% were in a stable relationship and
showed better QoL scores in physical functioning, general health
perceptions, and social functioning in comparison with single
individuals. Conversely, in a study with 209 Chinese trans
women, not having regular partner was positively associated with
the mental and physical component of QoL (40). The higher
prevalence of depression described by previous studies in the
group of Chinese trans women in a stable relationship might
be explained by the fear of losing their partners or suffering
discrimination from them (41).
We identified that most individuals in our sample had more
than 9 years of formal education. This subgroup had better
QoL scores, with no significant difference between trans women
and trans men. In terms of occupation, while most of our
trans women were employed, no difference was found in QoL
between employed and unemployed individuals. In trans men,
we observed that employed individuals had better scores in
the physical and psychological domains when compared to
unemployed individuals or students. In the literature, data on
education are conflicting (18,20), but previous studies suggest
that being employed is associated with better QoL in trans
individuals (15,18). In the study of Valashany and Janghorbani
(20), with 71 individuals who were employed or worked on
their own, most with secondary or higher education levels, a
Frontiers in Psychiatry | www.frontiersin.org 7July 2021 | Volume 12 | Article 621075
Silva et al. Well-being in Transgender Individuals Using Hormones
significant relationship was observed between education and
subscales of emotional well-being and social function, between
economic status and physical function subscale, and between
employment status and physical and social function. In another
study using the Short Form Health Survey (SF-36) with 61 trans
individuals, most of whom were employed and had more than
12 years of schooling, no significant difference was observed
in terms of education; however, those with employment had
higher QoL scores in the physical function and vitality domains
(18). Similarly, it was observed in the study of Gómez-Gil (15)
in which 61% of the individuals were employed or studying,
having an occupation had a positive association with the physical
domain, social relation, environment, and general QoL scores,
but no significant difference was observed in relation to the level
of education.
Regarding physical characteristics, increased breast
development was significantly associated with a higher score
in the physical domain in trans women. In a study assessing
body uneasiness and psychiatric symptoms in transgender
individuals, a decrease in body discomfort was observed in trans
women who used GAHT compared to those who did not use
hormone therapy. The body characteristics that caused greater
dissatisfaction were presence of body hair, smell, arms, thorax,
buttocks, and eyes (42). Interestingly, no significant difference
was found in quality of life between trans women with and
without breast implants in the present study. Similarly, in a
study conducted with 39 trans women, there was no difference
in quality of life scores in trans women regarding breast implants
(21). Breast development is generally perceived from 6 months
to 2 years after the onset of hormone therapy, being different in
each subject (6). In some cases, surgical intervention is necessary,
but in other cases the individuals are satisfied with the size of
their breast after GAHT.
In the present study, we found no significant differences
between trans men with mastectomy and QoL, which differs
from the results of other studies (8,43). Newfield et al.
(8) evaluated 136 trans men submitted to mastectomy and
observed higher QoL scores in these individuals when compared
to patients who had not performed mastectomy. Mastectomy
appears to improve the identity of trans men, increasing self-
esteem and the confidence to take off their T-shirts in favorable
environments (8).
Trans men with increased body hair had higher scores in
the physical, psychological, and social domains. In fact, beard
growth can cause a significant change in the way trans men are
perceived. Phenotypic alterations seem to be positively associated
with amelioration of body image by individuals in GAHT, and
this may contribute to significant improvement in interpersonal
relations (36).
Literature data are limited regarding the status of physical
activity in transgender individuals. In trans men, being physically
active was significantly associated with a higher score in
the physical, psychological, social relations, and environment
domains. In a British study with a small sample size, transgender
men were found to be less active despite being motivated to
exercise to increase body satisfaction and congruence with the
desired gender (44). These individuals reported that they lacked
safe spaces for physical activity and adequate facilities to change
clothing. They also mentioned body dissatisfaction and the
concern that they would not be accepted by others (44). The
same authors also reported that transgender individuals were less
engaged in physical activity than cisgender individuals. However,
using GAHT was linked to increased engagement in physical
activity and greater body satisfaction when compared to not
using GAHT (45).
In our study, there was no significant difference in the QoL
scores in relation to HIV serology, which is in accordance
with the literature (34). Most patients, however, were being
treated with antiretroviral drugs. Trans women present higher
prevalence of STIs, possibly due to social, biological, and
behavioral factors (46). A meta-analysis with 11,066 trans
women from 15 countries showed a prevalence of HIV infection
of 19.1%, with an odds ratio of 48.8 (95% CI 21.2–76.3)
for trans women being infected compared with adults in
reproductive age (47).
The overall QoL score was similar between trans men
and trans women. This was also observed by another study
with 61 trans individuals, in which no differences were
observed in QoL scores between trans men and trans
women (18). Conversely, a study with 94 trans individuals
reported better QoL scores in trans men in relation to trans
women, especially in physical functioning and general health
perception (21). Finally, a meta-analysis with 14 studies and
1,950 individuals revealed that transgender individuals showed
worse QoL related to mental health when compared to the
general population. However, those results did not remain
significant in a second analysis focusing only on GAHT
participants (48).
The present study has strengths, including the presentation
of novel data on Brazilian transgender individuals, a less well-
represented population in studies about factors associated with
QoL. Also, the sample only included individuals who met DSM-5
criteria for gender dysphoria and were in regular use of GAHT.
Limitations of this study include the lack of a control group
and the relatively small sample size, precluding complementary
analyses. In addition, further studies on body composition are
needed in order to deepen the understanding of findings related
to BMI.
CONCLUSION
Data from this study suggest that GAHT-related physical
characteristics (breast development in trans women and
increased body hair in trans men) are similarly associated
with higher QoL scores. Stable relationships are also
associated positively with higher QoL in both groups.
Regarding trans men, being physically active and being
employed contributed to better QoL. Further studies
with transgender people from other regions with distinct
socio-cultural traits could confirm and expand the present
results. Healthcare providers may take these factors into
consideration when planning interventions to improve QoL in
transgender individuals.
Frontiers in Psychiatry | www.frontiersin.org 8July 2021 | Volume 12 | Article 621075
Silva et al. Well-being in Transgender Individuals Using Hormones
DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by CAAE 79656117.5.0000.5327. The
patients/participants provided their written informed consent to
participate in this study.
AUTHOR CONTRIBUTIONS
ES, TF, and PS were involved in the conception and design of
the study, contributed to analysis and interpretation of data,
and drafted the manuscript. ES, TF, and RA contributed to data
collection. ML revised the manuscript for intellectual content. All
the authors read and approved the final manuscript.
FUNDING
This work was supported by the Brazilian National Institute
of Hormones and Women’s Health/Conselho Nacional de
Desenvolvimento Científico e Tecnológico (CNPq) grant
number CNPq/INCT 465482/2014-7 and Fundação de Amparo
à Pesquisa do Rio Grande do Sul (FAPERGS), grant number
FAPERGS/INCT 17/2551-0000519-8. Financial support was also
provided by FIPE-HCPA (Hospital de Clínicas de Porto Alegre
Research and Event Support Fund). The funders had no role in
study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
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Conflict of Interest: The authors declare that the research was conducted in the
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