The Role of Gender-Affirming Surgery and Hormone Therapy in the Development of Substance Use and Psychological Disorders in Assigned Males at Birth with Gender Dysphoria

INTRODUCTION: The decision to undergo gender affirming surgery is difficult for individuals with gender dysphoria disorder due to cost, recovery time, and possible complications. It is well–established that transgender individuals have higher rates of mental health disorders and substance use than the general population, but the effects of gender affirming surgery and hormone therapy on mitigating these factors are less understood. Our aim is to see if gender-affirming surgery in addition to hormone therapy has a protective role against the development of mental health and substance use disorders, compared with hormone therapy alone. METHODS: A retrospective analysis was conducted using TriNetX, a multi-institutional de-identified database that operates through Current Procedure Terminology (CPT) and International Classification of Diseases (ICD) codes. Assigned males at birth (AMAB) over 18 years of age with a diagnosis of gender dysphoria disorder within TriNetX from inception to January 2024 were included in the study. The cohort only included individuals on hormone therapy. The cohort was then separated based on undergoing gender affirming surgery. If a patient had a previous substance use disorder or psychological disorder, they were removed from that specific analysis. Risks of developing Opioid Use Disorder (OUD), Cannabis Use Disorder (CUD), Alcohol Use Disorder (AUD), cocaine dependence, nicotine dependence, depression, anxiety, and attempted suicide were determined any time following diagnosis in the non-surgical group, and starting 1 day after surgery in the surgical group. Propensity score matching was used to balance cohorts based on age, race, and ethnicity. A p-value <0.05 was used to determine statistical significance. RESULTS: After selection criteria were met, 19,984 AMAB were in the non-surgical cohort while 1,341 AMAB were in the surgical cohort. Following propensity score matching 1,341 AMAB remained in both groups. AMAB who did not receive gender affirming surgery had a higher risk of developing OUD (p=0.175), CUD (p=0.006), AUD (p=0.171), cocaine dependence (p=0.986), nicotine dependence (p<0.007), depression (p<0.007), anxiety (p<0.001), and OCD (p=0.839) than individuals who did receive surgery. There was no difference in suicide attempts. CONCLUSION: Based on our study, AMAB with gender dysphoria on hormone therapy who did not receive gender affirming surgery had a higher risk of developing OUD, CUD, AUD, nicotine dependence, depression, and anxiety than those who did receive surgery. This data suggests that gender affirming surgery may play a positive role in improving quality of life in AMAB with gender dysphoria disorder, compared with hormone therapy alone.