Do hormones and surgery improve the health of adults with gender incongruence? A systematic review of patient reported outcomes

Abstract

Background: Gender diverse people in Australia have higher levels of psychological stress, suicidal ideation and suicide attempts and have poorer self-reported health than cisgender people.

Objectives: To determine if adults who experience gender incongruence have improved health-related quality of life and mental health with gender affirming treatment (hormone therapy and surgery), compared with no treatment.

Data sources: PubMed, Web of Science, Embase and Psych Info.

Review methods: A systematic review of peer-reviewed publications in English from January 2010 to October 2022. Studies were included where: participants were treated with gender affirming surgery or hormone therapy for minimum 3 months and; validated patient reported outcome measures of health-related quality of life or mental health were reported. Quality of evidence assessment was undertaken using the Let Evidence Guide Every New Decision evaluation tool.

Results: Eighty-one publications were included for analysis. The systematic review indicated that there were significant improvements in the domains of mental illness, gender dysphoria, body image and health-related quality of life following gender affirming medical treatment as measured by a variety of patient reported outcomes. Meta-analysis showed significant improvement in body image (z = 4.47, P < 0.001) and health-related quality of life for psychological (z = 1.99, P = 0.047) and social relationships (z = 3.09, P = 0.002) following gender affirming surgery.

Conclusions: There is evidence that hormones and surgery as a collective for adults with gender incongruence has therapeutic value and should be considered for funding within Australia's healthcare systems. The development and implementation of patient-reported outcome tools tailored for purpose (GENDER Q) will facilitate future research.

Keywords: gender‐affirming care; systematic review.

Fig. 1

PRISMA flow diagram displaying study identification and selection. Created from PRISMA 2020 flow diagram.

Fig. 2

World map outlining the geographical dispersion of studies included in the review. Created with mapchart.net.

Fig. 3

Forest plot of prospective cohort studies reporting patient‐reported outcomes relating to mental health following gender‐affirming treatment. For scales indicated in blue, scores have been flipped, so that for all scales favourable results are to the right and unfavourable results are to the left of the centre line.

Fig. 4

Forest plot of prospective cohort studies reporting patient‐reported outcomes relating to gender dysphoria following gender‐affirming treatment. For scales indicated in blue, scores have been flipped, so that for all scales favourable results are to the right and unfavourable results are to the left of the centre line.

Fig. 5

Forest plot of prospective cohort studies reporting patient‐reported outcomes relating to self‐esteem and body image following gender‐affirming treatment. For scales indicated in blue, scores have been flipped, so that for all scales favourable results are to the right and unfavourable results are to the left of the centre line.

Fig. 6

Forest plot of prospective cohort studies reporting patient‐reported outcomes relating to generic health‐related quality of life following gender‐affirming treatment.

Fig. 7

Forest plot of prospective cohort studies reporting patient‐reported outcomes relating to condition specific health‐related quality of life following gender‐affirming treatment. For scales indicated in blue, scores have been flipped, so that for all scales favourable results are to the right and unfavourable results are to the left of the centre line.

Fig. 8

Meta‐analysis of patient‐reported outcome measures (a) body image disturbance using the Body Image Scale (b) self‐esteem using the Rosenburg Self‐esteem Scale (c) health‐related quality of life using the World Health Organization Quality of Life Scale – environmental domain (d) health‐related quality of life using the World Health Organization Quality of Life Scale – physical domain (e) health‐related quality of life using the World Health Organization Quality of Life Scale – psychological domain (f) health‐related quality of life using the World Health Organization Quality of Life Scale – social relationships domain.