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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. 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.
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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 (79).
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 (1012). 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
Frontiers in Psychiatry | www.frontiersin.org 6July 2021 | Volume 12 | Article 621075
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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The handling editor is currently co-organizing a Research Topic with one of
the author ML, and confirms the absence of any other collaboration.
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Frontiers in Psychiatry | www.frontiersin.org 10 July 2021 | Volume 12 | Article 621075
... Assim como observado por Silva, et al., (2021), a cirurgia de redesignação de gênero promoveu a melhoria dos aspectos psicológicos e das relações sociais, porém, os autores observaram que, mesmo um ano após, os transexuais de MtF continuam a relatar problemas de saúde física e dificuldade em recuperar sua independência. ...
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... The initiation of GAHT is significantly and positively associated with improvements in emotional well-being, social functioning and quality of life. 3,4 Transgender women are generally treated with oestrogens and anti-androgens, whereas transgender men are treated with testosterone. The long-term physiological impacts of GAHT are not well studied. ...
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Background: Gender-affirming hormone therapy (GAHT) is prescribed to produce secondary sex characteristics aligning external anatomy with gender identity to mitigate gender dysphoria. Transgender women are generally treated with oestrogens and anti-androgens, whereas transgender men are treated with testosterone. The objective of this narrative review was to characterise the influence of GAHT on body composition and bone health in the transgender population to help address weight concerns and chronic disease risk. Methods: Studies were extracted from PubMed and Scopus and limited to only those utilising imaging technologies for precise adipose tissue, lean mass, and bone mineral density (BMD) quantification. Results: Although methodologies differed across the 20 investigations that qualified for inclusion, clear relationships emerged. Specifically, among transgender women, most studies supported associations between oestrogen therapy and decreases in lean mass and increases in both, fat mass and body mass index (BMI). Within transgender men, all studies reported associations between testosterone therapy and increases in lean mass, and although not as consistent, increases in BMI and decreases in fat mass. No consistent changes in BMD noted for either group. Conclusions: Additional research is needed to appropriately assess and evaluate the implications of these body composition changes over time (beyond 1 year) in larger, more diverse groups across all BMI categories. Future studies should also seek to evaluate nutrient intake, energy expenditure and other important lifestyle habits to diminish health disparities within this vulnerable population. Policies are needed to help integrate registered dietitians into the routine care of transgender individuals.
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Objective: The impact of gender-affirming hormone therapy (GAHT) on cardiovascular health is still not entirely established. A systematic review was conducted to summarize the evidence on the risk of subclinical atherosclerosis in transgender people receiving GAHT. Methods: A systematic review was performed following PRISMA guidelines, and data were searched in PubMed, LILACS, EMBASE, and Scopus databases for cohort, case-control, and cross-sectional studies or randomized clinical trials, including transgender people receiving GAHT. Transgender men and women before and during/after GAHT for at least 2 months, compared with cisgender men and women or hormonally untreated transgender persons. Studies reporting changes in variables related to endothelial function, arterial stiffness, autonomic function, and blood markers of inflammation/coagulation associated with cardiovascular risk were included. Results: From 159 potentially eligible studies initially identified, 12 were included in the systematic review (8 cross-sectional and 4 cohort studies). Studies of trans men receiving GAHT reported increased carotid thickness, brachial-ankle pulse wave velocity (baPWV), and decreased vasodilation. Studies of trans women receiving GAHT reported decreased IL-6, PAI-1 and tPA levels and baPWV, with variations in FMD and arterial stiffness depending on the type of treatment and route of administration. Conclusions: The results suggest that GAHT is associated with an increased risk of subclinical atherosclerosis in transgender men but may have either neutral or beneficial effects in transgender women. The evidence produced is not entirely conclusive, suggesting that additional studies are warranted in the context of primary prevention of cardiovascular disease in the transgender population receiving GAHT.
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Este estudo descreve o perfil sociodemográfico e farmacoterapêutico de pessoas transgênero de um ambulatório especializado em Sergipe, nordeste do Brasil. Esta investigação é uma pesquisa observacional, transversal e retrospectiva desenvolvida de janeiro a maio de 2022 com amostragem por conveniência. Os dados incluídos na análise foram o número de prontuário, idade, gênero, anos de estudo e estado civil. Também foram coletadas do prontuário eletrônico informações sobre o uso de medicamentos, como o tipo de hormonioterapia e outros medicamentos utilizados atualmente, prescritos ou não. A análise descritiva envolveu medidas de tendência central (média, mediana e desvio padrão). As pessoas transgênero incluídas no estudo (n=81) tinham até 29 anos (80%) (idade mediana de 26 anos), 70% (n=57) relataram o uso de hormonioterapia, sendo que 17% (n=10) desses relataram automedicação. A formulação mais utilizada foi o cipionato de testosterona 40,8% (n=20), seguido do acetato de ciproterona mais estradiol 20,4% (n=10). Cerca de 66,7% (n=38) dessas pessoas usavam outros medicamentos, como antidepressivos (32%; n=24). Por ser uma população minoritária que enfrenta constantemente situações de vulnerabilidade social, este trabalho contribuirá para uma caracterização mais detalhada dessa população do serviço investigado. Assim, órgãos públicos e organizações que atendem essa população podem obter mais informações sobre a diversidade que a compõe.
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The use of gender-affirming hormone therapy is found almost universally in transgendered and nonbinary patients presenting for gender-affirming surgical procedures of the face, neck, and voice. Surgeons caring for this population need to be aware of the effects, reasonable expectations, and limitations as well as potential perioperative risks of both continuation and discontinuation of hormone therapy.
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Objective: The objective of the review was to evaluate the effectiveness of cross-sex hormone use in improving quality of life and the related measures of depression and anxiety in the transgender population versus no use of cross-sex hormones. Introduction: Transgender medicine as a specialty is still in its infancy and is beginning to attract more primary care providers. The use of hormones to aid in gender transition is expected to provide benefit with regard to quality of life, but there have been few high-quality studies. Two previous systematic reviews were found. One review included studies where participants had gender-affirming surgery, and the other review considered only prospective studies. Both reviews found a benefit with the use of hormones, despite the lack of high-quality studies. To describe outcomes specifically associated with hormone therapy, this review focused on patients who had not yet had surgical interventions, with an aim to inform primary care providers who are considering providing gender transition related-care in their office or clinic. Inclusion criteria: Studies were considered that included participants who were trans women, trans men or who did not identify with the gender binary and were using cross-sex hormones. This review only considered studies where the hormone use was under medical supervision. Studies that included participants who already had any form of gender-affirming surgery among those who used hormones were excluded, as were studies that did not use a validated tool to measure quality of life, depression or anxiety. Methods: A comprehensive database search of PubMed, CINAHL, Embase and PsycINFO was conducted in August and September of 2017. The search for unpublished studies and grey literature included Google, the New York Academy of Medicine and the World Professional Association for Transgender Health (WPATH) Conference Proceedings. No date limits were used in any part of the search. Study selection, critical appraisal and data extraction were conducted by two independent reviewers using the Joanna Briggs Institute protocols, standardized critical appraisal and data extraction tools. Results: Seven observational studies met the inclusion criteria for this review. The total number of transgender participants in all the included studies was 552. Population sizes in the studies ranged from 14 to 163. In general, the certainty of the findings was low to very low due to issues with imprecision and indirectness. The use of cross-sex hormones was associated with improved quality of life, depression and anxiety scores, although no causation can be inferred. Conclusions: Transgender participants who were prescribed cross-sex hormones had statistically significant scores demonstrating improvement on the validated scales that measured quality of life, anxiety and depression when compared to transgender people who had enrolled in a sex-reassignment clinic but had not yet begun taking cross-sex hormones. However, because the certainty of this evidence was very low to low, recommendations for hormone use to improve quality of life, depression and anxiety could not be made. High-quality research on this issue is needed, as is the development of a quality-of-life tool specific to the transgender population.
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Background: The aim of this study was to evaluate the self-reported perceived quality of life (QoL) in female to male (FTM) and male to female (MTF) transgenders and compare it with a general population sample, and to find possible determinants that likely contribute to their QoL. Methods: Participants were 71 trandgenders participating in the communities of Isfahan and Fars provinces, Iran, including 30 MTF and 41 FTM, and 142 gender- and age-matched controls. Persian version of the Short Form 36-Item Questionnaire was used to evaluate self-reported QoL, which measures QoL across eight domains. Results: Compared to control group, the QoL of transgenders in the most dimensions of the SF-36 questionnaire was lower. MTF had a lower QoL than FTM for the subscale physical functioning (p = 0.044). There was a significant relationship between education and subscales of emotional well-being (p = 0.048) and social function (p = 0.008); economic status and physical function subscale (p = 0.003); employment status and physical function (p = 0.012) and social function subscales (p = 0.003). Compared to male controls, MTF transgenders had lower physical functioning (P < 0.001), role limitation due to physical health (P = 0.015), vitality (P = 0.023), social functioning (P < 0.001) and pain score (P = 0.044) and no significant differences between female controls and FTM transgenders were seen. Conclusion: Transgenders have lower physical and mental QoL, FTM transgender has better QoL than MTF transgender. Employment, education, province of residence and economic status as well as therapeutic intervention is associated with transgender's QoL.
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The study aims to systematically extract and analyse data about Quality of Life (QoL) in the transgender population. A systematic literature search and meta-analysis were conducted using the MEDLINE, EMBASE, PubMed, and PsycINFO databases, up to July 2017. Only English language quantitative studies, in adults, which reported the means for validated QoL measures were included. Random-effect meta-analysis was adopted to pool data and estimate the 95% Confidence Intervals (CI). From 94 potentially relevant articles, 29 studies were included within the review and data extraction for meta-analysis was available in 14 studies. The majority of the studies were cross-sectional, lacked controls and displayed moderate risk of bias. Findings from the systematic review suggested that transgender people display poor QoL, independent of the domain investigated. Pooling across studies showed that transgender people report poorer mental health QoL compared to the general population (-0.78, 95% CI= -1.08 to -0.48, 14 studies). However, meta-analysis in a subgroup of studies looking at QoL in participants who were exclusively post-CHT found no difference in mental health QoL between groups (-0.42, 95% CI= -1.15 to 0.31; 7 studies). There was insufficient data for a pre-treatment subgroup. Evidence suggests that transgender people have lower QoL than the general population. Some evidence suggests that QoL improves post-treatment. Better quality studies that include clearly defined transgender populations, divided by stage of gender affirming treatment and with appropriate matched control groups are needed to draw firmer conclusions.
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Objective To update the “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2009. Participants The participants include an Endocrine Society–appointed task force of nine experts, a methodologist, and a medical writer. Evidence This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus Process Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. Conclusion Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person’s affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)—should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
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Gender affirming treatment for transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen lowering medications. Feminizing treatment with estrogens and anti-androgens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk of venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses plus increase of muscle mass, facial and body hair. Due to the lack of evidence, treatment for gender non-binary people should be individualized. Young people may receive pubertal suspension, consisting of gonadotrophin-releasing hormone analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur, but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to effect of gender affirming treatment in the non-binary population.
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Objective: Cross-sex hormonal therapy (CHT) in trans persons affects their total body fat and total lean body mass. However, it is unknown how separate body regions are affected and whether these changes alter body shape. Therefore, the aim of this study was to determine the effects on body fat and lean body mass in separate body regions and on body shape after one year of CHT. Design and methods: In a multicenter prospective study at university hospitals, 179 male-to-female gender dysphoric persons, referred to as transwomen, and 162 female-to-male gender dysphoric persons, referred to as transmen, were included. All underwent whole-body dual-energy X-ray absorptiometry and anthropometric measurements before and after one year of CHT. Results: In transwomen, increases in body fat ranged from +18% (95% CI: 13%;23%) in the android region to +42% (95% CI: 37%;46%) in the leg region and +34% (95% CI: 29%;38%) in the gynoid region. In transmen, changes in body fat ranged from -16% (95% CI: -19;-14%) in the leg region and -14% in the gynoid region (95% CI: -16%;-12) to no change in the android region (+1%, 95% CI: -3%;5%). Waist-to-hip ratio (WHR) decreased in transwomen (-0.03, 95% CI: -0.04;-0.02) mainly due to an increase in hip circumference (+3.2 cm, 95% CI: 2.3;4.0). Transmen have a decrease in hip circumference (-1.9 cm, 95% CI: -3.1;-0.7) resulting in an increase in WHR (+0.01, 95% CI: 0.00;0.02). Conclusions: CHT causes a more feminine body fat distribution and a lower WHR in transwomen and a more masculine body fat distribution with a lower hip circumference in transmen.
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Background: Physical activity has been found to alleviate mental health problems and could be beneficial for at-risk populations, such as transgender people. This study had three aims. First, to explore the amount of physical activity that treatment seeking transgender people engage in, and to compare this to matched cisgender people. Second, to determine whether there was a difference in physical activity depending on cross-sex hormone use. Third, to determine factors which predict physical activity among treatment seeking transgender people. Method: Transgender (n=360) and cisgender people (n=314) were recruited from the UK. Participants were asked to complete questionnaires about physical activity, symptoms of anxiety and depression, self-esteem, body satisfaction and transphobia. Results: Transgender people engaged in less physical activity than cisgender people. Transgender people who were on cross-sex hormones engaged in more physical activity than transgender people who were not. In transgender people on cross-sex hormones, high body satisfaction was the best statistical predictor of physical activity while high self-esteem was the best statistical predictor in people who were not. Conclusion: Transgender people are less active than cisgender people. Cross-sex hormone treatment appears to be able to indirectly increase physical activity within this population, which may be beneficial for mental well-being.
Article
Background: Transgender people (those who feel incongruence between the gender they were assigned at birth and their gender identity) engage in lower levels of physical activity compared to cisgender (non-transgender) people. Several factors have been shown to affect physical activity engagement in the cisgender population; however, the physical activity experiences of young transgender adults have not been explored. It is therefore the aim of the current study to understand what factors are associated with physical activity and sport engagement in young transgender adults who are medically transitioning. Method: Semi-structured interviews were conducted with 14 young transgender adults (18–36 years) who had initiated their medical transition at a transgender health service in the United Kingdom. The data were analyzed using thematic analysis. Results: Two main themes were identified: (1) barriers and (2) facilitators to physical activity and sport. Overall, the young transgender adults were insufficiently active due to inadequate changing facilities, body dissatisfaction, fears surrounding “passing” and not being accepted by others. At the same time, participants were motivated to engage in physical activity to increase their body satisfaction and gender congruence. However, participants felt there was a lack of safe and comfortable spaces to engage in physical activity and sport. Conclusion: Young transgender adults who are medically transitioning experience several barriers to physical activity and sport, despite being motivated to be physically active. Initiatives to facilitate young transgender adults' ability to put their motivations into practice (i.e. to be more physically active) are needed.