The Relationship Between Gender-Affirming Procedures, Body Image Quality of Life, and Gender Affirmation
Abstract
This study explored whether self-reported barriers to accessing a health care provider, gender-affirming procedures, and relevant psychosocial measures were related to experienced gender affirmation in a cross-sectional sample of trans individuals (N=101). Body image quality of life [b=0.181, t(4.277), p<0.001] and the number of gender-affirming procedures [b=0.084, t(2.904), p=0.005] were significant predictors of transgender congruence, a measure of gender affirmation, and accounted for 40% of the adjusted variance in transgender congruence scores F(2, 89)=31.363, p<0.001, R2=0.413. Results suggest that experiencing a barrier to gender-affirming health care is associated with anticipation of discrimination and provides further evidence that gender-affirming health care is associated with positive psychosocial outcomes.
Introduction
People whose gender identity differs from their sex assigned at birth may self-identify with the umbrella term transgender (trans), which encompasses a heterogeneous group of trans masculine, trans feminine, and gender-diverse people.1 A consensus on the number of trans adults in the United States is lacking, although a 2016 analysis of Behavioral Risk Factor Surveillance System (BRFSS) data estimated that there are 1.4 million trans U.S. adults.2 Although every transition is unique, some trans individuals may experience gender dysphoria—a condition recognized by the American Psychiatric Association characterized by discomfort that may arise in people whose gender identity differs from sex assigned at birth.
Gender dysphoria is associated with clinically significant impairment on psychological well-being.3 Some, but not all, trans people may seek gender-affirming procedures, such as hormone therapy, to affirm gender identity.1 Gender-affirming procedures can have mental, physical, and social benefits and are a key determinant to the health and well-being of trans individuals; as such, the World Professional Association for Transgender Health recognizes gender-affirming procedures as medically necessary treatment for gender dysphoria.4 Moreover, such procedures can contribute to a construct known as gender affirmation, a broad term to describe cumulative interpersonal experiences of one's gender identity or expression being affirmed.5
Barriers to gender-affirming health care are well documented despite the promise of gender-affirming procedures to improve the well-being of trans individuals.4 Limited access to health care services and discrimination in health care settings—including denial of health care entirely, inadequately educated health care providers, and under-or lack-of health insurance—occur extensively across the life course.6–9
Despite known barriers and the potential of gender-affirming procedures to improve quality of life, the effect of these experiences on gender affirmation remains underdeveloped. This exploratory analysis examined the relationship between demographics, self-report occurance of any barrier to accessing a health care provider, gender-affirming procedures, and relevant psychosocial measures to inform understanding of experiences of gender affirmation.
Methods
This is a secondary analysis of a cross-sectional online Qualtrics survey of trans people (N=101) across the United States about experiences with nonsurgical injectable procedures—cosmetic treatments that can enhance the appearance of the face.10 Data were collected between December 2019 and February 2020. Eligible participants identified as trans, were at least 18 years of age, and spoke and read English. Each participant provided informed consent prior to beginning the survey. The Temple University Institutional Review Board approved this research (protocol number 26234).
Independent demographic variables included age, gender identity (transfeminine [yes/no]; transmasculine [yes/no]; gender-diverse [yes/no]), and race (white/nonwhite). Participants self-reported history of gender-affirming procedures that included hormone replacement therapy, nonsurgical injectable procedures, voice therapy, breast augmentation or mastectomy, feminizing or masculinizing facial procedures, orchiectomy or hysterectomy and oophorectomy, and vaginoplasty or phalloplasty or metoidioplasty. A composite score from 0 (no reported history of gender-affirming procedures) to 7 (the maximum number of response options) was used to create an ordinal 0–7 scale.
Based on previous research,10 the analysis also included experienced pressure to modify physical appearance in the past 6 months (yes/no), barrier to accessing a health care provider within the past year (yes/no), body image quality of life,11 self-esteem assessed through the Rosenberg Self-esteem scale,12 the degree to which participants anticipated discrimination related to intersectoral components of identity (e.g., race, gender identity, and sexual orientation) measured through the Intersectional Anticipated Discrimination scale,13 and gender affirmation measured by the Transgender Congruence Scale.14
Categorical variables were analyzed descriptively (frequencies and percentages) and associations between race, gender, pressure to change appearance, and barrier to accessing a health care provider were assessed using chi square tests of independence. Distribution in age and number of gender-affirming procedures was also assessed, as were mean differences by barrier accessing a health care provider, using independent samples t-tests. The Mann–Whitney U test assessed differences in distributions of body image quality of life, self-esteem, Intersectional Anticipated Discrimination, and transgender congruence scores by experience of barrier accessing a health care provider; mean ranks are presented.
To further explicate the relationship between these variables and gender affirmation, stepwise regression was used to identify which of the 10 candidate variables already described accounted for variance in the outcome, gender affirmation, which was assessed by the Transgender Congruence Scale.14 Before regressing, Spearman rank correlations were examined to assess for multicollinearity between the 10 candidate variables. Model fit was analyzed using the F-statistic and variables were retained if regression coefficients were significant at the p<0.05 level. Data were analyzed in IBM SPSS for Mac, Version 25.0.
Results
Spearman's rank correlations are presented in Table 1; all candidate variables were retained for entry into the model. Stepwise regression produced a significant model where body image quality of life [b=0.181, t(4.277), p<0.001] and number of gender-affirming procedures [b=0.084, t(2.904), p=0.005] were significant predictors of gender affirmation, accounting for 40% of the adjusted variance F(2, 89)=31.363, p<0.001, R2=0.413.
Variable | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
---|---|---|---|---|---|---|---|---|---|---|---|
1. Transgender congruence | — | ||||||||||
n | |||||||||||
2. Age | 0.224a | — | |||||||||
n | 97 | ||||||||||
3. Race | 0.123 | 0.108 | — | ||||||||
n | 101 | 97 | |||||||||
4. Gender | −0.145 | −0.114 | 0.067 | — | |||||||
n | 101 | 97 | 101 | ||||||||
5. Gender-affirming procedures | 0.539b | 0.173 | 0.273a | −0.207a | — | ||||||
n | 101 | 97 | 101 | 101 | |||||||
6. Appearance pressure | −0.454b | −0.332b | −0.017 | −0.026 | −0.474b | — | |||||
n | 96 | 92 | 96 | 96 | 96 | ||||||
7. Barrier accessing a health care provider | 0.038 | 0.088 | −0.048 | 0.079 | −0.089 | 0.042 | — | ||||
n | 101 | 97 | 101 | 101 | 101 | 96 | |||||
8. Self-esteem | 0.357b | 0.163 | −0.026 | −0.041 | 0.282b | −0.330b | 0.004 | — | |||
n | 101 | 97 | 101 | 101 | 101 | 96 | 101 | ||||
9. Facial appearance satisfaction | 0.232a | 0.026 | 0.270b | 0.008 | 0.255b | −0.286b | 0.091 | 0.152 | — | ||
n | 101 | 97 | 101 | 101 | 101 | 96 | 101 | 101 | |||
10. Body image quality of life | 0.564b | 0.337b | 0.297b | 0.050 | 0.510b | −0.483b | 0.036 | 0.379b | 0.352b | — | |
n | 101 | 97 | 101 | 101 | 101 | 96 | 101 | 101 | 101 | ||
11. Intersectional anticipated discrimination | −0.153 | −0.033 | 0.026 | 0.057 | −0.321b | 0.287b | 0.226a | −0.217a | −0.015 | −0.153 | — |
n | 101 | 97 | 101 | 101 | 101 | 96 | 101 | 101 | 101 | 101 |
a
p<0.05.
b
p<0.01.
There were no statistically significant differences in demographic variables by experienced barrier accessing a health care provider (Table 2). Intersectional Anticipated Discrimination scores among participants who experienced a barrier accessing a health care provider within the past year (n=35) were significantly higher than those who did not experience at least one health care barrier accessing a health care provider within the past year (n=66) (mean rank=60.04 vs. 46.20, p=0.024). Mean rank body image quality of life (52.44 vs. 50.23, p=0.718), self-esteem (51.16 vs. 50.92, p=0.969), and transgender congruence (52.53 vs. 50.19, p=0.702) scores did not significantly differ between those who did experience at least one barrier to accessing a health care provider and those who did not.
Variable | Total sample (N=101) | Barrier accessing health care provider | p | ||||
---|---|---|---|---|---|---|---|
Yes (n=35) | No (n=66) | ||||||
Age (n=97), M (SD)a | 30.18 | 8.75 | 29.44 | 4.78 | 30.54 | 10.16 | 0.563 |
Race, n (%)b | |||||||
White | 72 | 71.3% | 26 | 74.3% | 46 | 69.7% | 0.628 |
Nonwhite | 29 | 28.7% | 9 | 25.7% | 20 | 30.3% | |
Gender, n (%)b | |||||||
Transfeminine | 58 | 57.4% | 19 | 54.3% | 39 | 59.1% | 0.492 |
Transmasculine | 31 | 30.7% | 10 | 28.6% | 21 | 31.8% | |
Gender diverse | 12 | 11.9% | 6 | 17.1% | 6 | 9.1% | |
Appearance modification pressure (n=96), n (%)b | |||||||
Yes | 44 | 45.8% | 17 | 48.6% | 27 | 44.3 | 0.683 |
No | 52 | 54.2% | 18 | 51.4% | 34 | 55.7 | |
No. of gender-affirming procedures, M (SD)a | 3.08 | 1.75 | 2.82 | 1.52 | 3.21 | 1.86 | 0.298 |
a
Statistical significance was calculated using an independent samples t-test.
b
Statistical significance was calculated using a chi-square test.
Discussion
Quality of life related to body image and number of gender-affirming procedures accounted for some variance observed in gender affirmation. These associations are unsurprising and align with the understanding that physical appearance dissatisfaction is a typical precursor to engagement with gender-affirming procedures, particularly for individuals who may pursue these procedures as treatment for gender dysphoria.1 The relationship in our sample between body image quality of life, gender-affirming procedures, and gender affirmation is consistent with other cross-sectional investigations that found that gender-affirming procedures have measurable body image-related benefits for those who desire them.15,16
That gender-affirming care and body image quality of life account for gender affirmation is further evidence in support of the American Psychological Association's recognition that gender-affirming care is of clinical value when pursued as treatment by individuals who experience gender dysphoria.1
We also found that participants who reported at least one barrier to accessing a health care provider within the past year had significantly higher mean rank Intersectional Anticipated Discrimination scores. Barriers to accessing a health care provider may lead to internalization of discrimination; this relationship may account for the elevated self-report belief in a likelihood of experiencing an act of discrimination. Anticipating discrimination could have implications on the health care seeking behaviors and well-being of trans people. An analysis of 2015 U.S. Transgender Survey data found that anticipated discrimination is associated with health care avoidance, particularly for trans men.17
Moreover, barriers to health care contribute to stigmas that are related to impaired mental and physical health among trans people.18 Thus, denying access to gender-affirming care instantiates harmful discrimination and may jeopardize psychosocial well-being. Subsequent investigations should evaluate how various barriers to gender-affirming care are associated with anticpated discrimination and health outcomes.
There are limitations to note. The measure of gender-affirming procedures assumes that each incremental increase in number of gender-affirming procedures contributes equally to the effect on transgender congruence, but this has not been established. Furthermore, race was categorized as white/nonwhite creating a false dichotomy that may minimize racial differences in results.
Future study should utilize electronic medical record data to capture history of gender-affirming procedures, and seek to include larger diverse samples, in which more advanced analyses are feasible to tease out unique contributions of gender-affirming procedures and assess whether there are racial differences in outcomes. This would inform the development of patient-reported outcome measures that should be standardized and adopted across prospective studies of patients undergoing gender-affirming procedures.
These findings also come at a time when the right to health care access for trans individuals is under renewed threat across the United States.19 As of March 2021, over 80 bills—more than any previous year—that aim to limit access to health care for trans youth and adults have been introduced in U.S. state legislatures.19 This new wave of antitrans legislation targeting trans Americans and their health care providers is troubling and contrary to these findings as well as existing data that indicate gender-affirming health care can have psychosocial benefits.10,15,16,20
Conclusions
The results of this study suggest that expanded access to gender-affirming procedures for trans individuals is warranted and has the potential to improve psychosocial outcomes. Investigations to come should include the voices of trans adolecents, as well as those who are gender diverse and nonbinary, to further understand experiences of gender affirmation. In addition, given the imminent threat to health care access for this population, further research that informs health policy should be conducted.
Abbreviation Used
- BRFSS
- Behavioral Risk Factor Surveillance System
References
1. American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70:832–864.
2. Flores AR, Herman JL, Gates GJ, Brown TNT. How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute, UCLA, 2016.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Washington, DC: American Psychiatric Association, 2013.
4. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13:165–232.
5. Sevelius JM. Gender affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68:675–689.
6. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168–171.
7. Grant J, Mottet L, Tanis J, et al. Injustice at Every Turn: a Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
8. James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality, 2016.
9. Cicero EC, Reisner SL, Silva SG, et al. Health care experiences of transgender adults: an integrated mixed research literature review. ANS Adv Nurs Sci. 2019;42:123–138.
10. Kelly PJ, Frankel AS, D'Avanzo P, et al. Psychosocial differences between transgender individuals with and without history of nonsurgical facial injectables. Aesthet Surg J Open Forum. 2020;3:ojaa050.
11. Cash TF, Fleming EC. The impact of body image experiences: development of the body image quality of life inventory. Int J Eat Disord. 2002;31:455–460.
12. Rosenberg M. Society and the Adolescent Self Image. Princeton, NJ: Princeton University Press, 1965.
13. Scheim AI, Bauer GR. The Intersectional Discrimination Index: development and validation of measures of self-reported enacted and anticipated discrimination for intercategorical analysis. Soc Sci Med. 2019;226:225–235.
14. Kozee HB, Tylka TL, Bauerband LA. Measuring transgender individuals' comfort with gender identity and appearance: development and validation of the Transgender Congruence Scale. Psychol Women Q. 2012;36:179–196.
15. Owen-Smith AA, Gerth J, Sineath RC, et al. Association between gender confirmation treatments and perceived gender congruence, body image satisfaction, and mental health in a cohort of transgender individuals. J Sex Med. 2018;15:591–600.
16. Becker I, Auer M, Barkmann C, et al. A cross-sectional multicenter study of multidimensional body image in adolescents and adults with gender dysphoria before and after transition-related medical interventions. Arch Sex Behav. 2018;47:2335–2347.
17. Kcomt L, Gorey KM, Barrett BJ, McCabe SE. Healthcare avoidance due to anticipated discrimination among transgender people: a call to create trans-affirmative environments. SSM Popul Health. 2020;11:100608.
18. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222–231.
19. Ronan W. Breaking: 2021 Becomes Record Year for Anti-Transgender Legislation. Human Rights Campaign, 2021. Available from: https://www.hrc.org/press-releases/breaking-2021-becomes-record-year-for-anti-transgender-legislation Accessed August 12, 2021.
20. Passos TS, Teixeira MS, Almeida-Santos MA. Quality of life after gender affirmation surgery: a systematic review and network meta-analysis. Sex Res Soc Policy. 2020;17:252–262.
Cite this article as: Kelly PJ, D'Avanzo PA, Shanker A, Suppes K, Frankel AS, Sarwer DB (2023) The relationship between gender-affirming procedures, body image quality of life, and gender affirmation, Transgender Health 8:3, 293–297, DOI: 10.1089/trgh.2021.0081.
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Copyright 2023, Mary Ann Liebert, Inc., publishers.
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Published in print: June 2023
Published online: 1 June 2023
Published ahead of print: 10 February 2022
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All authors meet the definition of authorship as defined by the International Committee of Medical Journal Editors.
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No competing financial interests exist.
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This study was supported by a Tempe University College of Public Health Visionary Research Award.
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