Gender Affirming Care isn’t a Panacea
We need to change the way we talk about — and research — the relationship between gender dysphoria and mental illness
What is the purpose of gender-affirming care?
This question is at the heart of the ongoing culture war around trans healthcare — a culture war being waged primarily by conservatives and the right, which makes trans people, and trans youth in particular, a target.
The answer is very simple: the purpose of gender-affirming care, and of gender transition, is the alleviation of gender dysphoria.
Of course, gender dysphoria can also be related to mental illness — but the relationship isn’t necessarily one of simple causation, and other factors are often at play.
Yet discussions around gender-affirming care and the way we research its efficacy often oversimplify the relationship between gender dysphoria and mental illness, while overlooking social factors — like transphobia — which affect trans people’s wellbeing.
Why?
Key to this issue is two concepts: comorbidity and multi-morbidity.
Comorbidity essentially prioritises one illness or condition, while noting the co-occurrence of others.
Multi-morbidity looks at all health conditions equally, considering the impact which each condition may or may nothave on the others, as well as the influence of social and other factors.
The problem is, there is often no clear distinction between when conditions are comorbid or multi-morbid. In reality, the interaction or relation of different health conditions is complicated (particularly in the case of mental illness), with the focus on comorbidity or multi-morbidity additionally being heavily dependent on the healthcare setting.
Someone presenting to a specialist service, like a gender clinic, would likely find that their gender dysphoria is treated as the primary condition.
The same person presenting to a more generalist service, such as a GP or family doctor, might find that all of their conditions are considered equally (with primacy potentially determined by elements of triage and patient preference).
This isn’t an issue under ideal conditions — the GP (primary care) would hopefully refer to various specialists (secondary care) to deal with the different conditions (though in the case of restrictive budgets and a lack of resources, as well as medical gatekeeping, this ideal situation isn’t always the reality).
A question of design
The question of comorbidity vs. multi-morbidity becomes a particular issue when designing research.
It might be true that a transgender person’s mental health conditions are mostly related to dysphoria; there are certain studies that demonstrate the positive impact of gender-affirming care on mental health problems.
However, it’s also true that mental illness can be the result of other individual or social factors.
This will vary greatly from one person to another — and it’s very hard to design studies that address this kind of variance, particularly in an area where studies are already hard to design for reasons of ethics and small population demographics.
Nonetheless, many studies use mental health conditions as a measure (or proxy) for the efficacy of gender-affirming care.
This is a comorbidity approach, with the expectation that the relationship between gender dysphoria and mental illness is (at least somewhat) causal in one direction and that any reduction in gender dysphoria as a result of gender-affirming care will be represented by a reduction in comorbid mental health issues.
A multi-morbidity approach might instead look at all of these conditions equally without assuming that one is the primary condition impacting the others. In doing so, it wouldn’t necessarily use one condition as a gauge for improvement of another (though might still note their interaction), while also taking into account social and environmental factors.
“[A] focus on multimorbidity enables the exploration of potentially causal associations among all coexisting conditions at once. This can identify common patterns and susceptibility to clusters of co-occurring diseases, whether these are genetic, biologic, and/or linked to the physical or social environment.”
— Harrison et al (2021) Comorbidity versus multimorbidity: Why it matters (para. 6).
This isn’t an issue limited to the study of gender-affirming care, but it becomes more important in the context of the intense cultural and political focus transgender healthcare receives.
We don’t exist in a vacuum
We know that mental illness in transgender people who experience gender dysphoria can have both individual and social causes — and yet we tend to focus more on the former.
For example, we know that discrimination, social exclusion, harassment, and their relationship with minority stress can have a huge impact on the mental health and well-being of transgender people.
The impact of these issues on our mental health is entirely separate from the gender dysphoria we experience — it is a result of how society treats us because we have gender dysphoria (because we are transgender), not gender dysphoria itself.
Expecting gender-affirming care to address this is thus unrealistic.
In addition, clinical research often fails to fully account for intersecting social factors like race and ethnicity, religion, social class, or income, aside from noting them for the sake of demographics.
Again, expecting gender-affirming care to address the effects of deep-seated social-structural factors which might not even relate directly to gender identity is unrealistic.
And yet, research into the efficacy of gender-affirming care rarely attempts to discern between mental health issues that are associated with dysphoria, those which are the result of social and structural factors, and those which are potentially independent of either.
Social variables
In fact, it’s possible that gender-affirming care and social factors might have contrasting outcomes for mental illness.
When we come out and begin to transition we will likely experience a lessening of our gender dysphoria, and possibly a reduction in some other mental health issues (depending of course on how much these other issues are related to our dysphoria).
At the same time, as we transition socially and come out to more people we might face more stigma, more harassment, more rejection from family and friends, discrimination in school or the workplace, and so on.
So even though our gender dysphoria improves with gender-affirming care, the mental health issues that come with the way society treats us for being transgender might become worse.
Yet if we were to participate in a study that only measured mental health outcomes after receiving gender-affirming care (a comorbid approach using mental illness as a proxy for gender dysphoria, considered in isolation from social factors), it would seem like transition had a little positive impact on our mental health or even made it worse.
Social factors are a hugely important confounding variable that often only gets a passing mention in clinical research papers for the sake of the literature review, or are mentioned off-hand as a possible factor impacting data, without any real investigation.
An open goal for pseudo-science
These two issues — a lack of consideration for social factors and a comorbid approach to the relationship between gender dysphoria and mental illness — present a huge problem for a field of medicine that is so culturally contested and vulnerable to misrepresentation and pseudo-scientific claims by bad faith actors.
It provides an opportunity for those opposed to gender-affirming care on ideological grounds to attack the evidence base for trans healthcare (and ironically attribute the impacts of the toxic political and social environment trans people are subject to, to the supposed failings of transgender healthcare).
For example, one recent article from two anti-trans academics (both of whom are associated with linked pseudo-scientific, anti-trans think tanks SEGM and Genspect) exploits this comorbid approach to the link between mental illness and dysphoria and the conflation of individual and social factors in an attempt to discredit the evidence base for gender-affirming care.
Likewise, literature reviews commissioned by the ongoing Cass Review into gender-affirming care for transgender youth, and similar reviews which were used as justification for the ban on gender-affirming care in Florida, all attempt to discredit the evidence base for gender-affirming care (at least partly) on the basis of these two issues.
Arguably these reviews are influenced by both ideology and systemic transphobia.
The Cass Review has been criticised for hiring researchers associated with the promotion of ‘conversion therapy’ and its commissioned reviews, criticised for ignoring international evidence and scientific consensus. The Florida review has been heavily criticised for making false claims, dismissing medical evidence, and relying on pseudo-science.
Unfortunately, those opposed to gender-affirming care will always attempt to misrepresent and discredit the evidence for transgender healthcare; that is not the fault of clinicians and researchers working in good faith to support and provide care to transgender people.
Nonetheless, it would be much more difficult for those opposed to gender-affirming care to erroneously discredit existing research and negatively influence policy if the evidence base was more robust, based on a better research design that addressed the issues of comorbidity/multi-morbidity and confounding social factors.
Without a care
Gender-affirming care is not a panacea for mental illness, but treatment for gender dysphoria — and we need to be more specific about that both in research design and in discourse.
The way we currently talk about gender-affirming care, the expectations we place upon it, and the way we assess its efficacy, currently provide ample opportunity for ideological opponents to portray transgender healthcare as a harmful failure.
These limitations have been used as the justification for the withdrawal of gender-affirming care, in turn resulting in a huge amount of harm to trans people.
It also provides ammunition for culture war rhetoric which in turn worsens the social conditions experienced by transgender people, further contributing to mental illness.
That’s obviously not the aim of those doing research on gender-affirming care, and it is to their credit that they continue to work on developing the evidence base and defending transgender healthcare under such intense political scrutiny.
However, because transgender healthcare has been politicised so much, researchers need to be cognisant of how research limitations might be weaponised — and the impact which this might have on transgender people and our access to necessary and beneficial healthcare.