Abstract
Purpose:
Many studies have shown conflicting results regarding mental health among transmasculine adults or transgender men (TM). This study aimed to identify the prevalence of depression among Thai TM receiving gender-affirming hormone therapy (GAHT).
Methods:
All TM, over 18 years of age, who received GAHT for at least three consecutive months were invited to complete a self-report questionnaire that covered participants' demographic and clinical data. Mental health, including depression, anxiety, and quality of life (QoL), was assessed. We reported the prevalence of mental illnesses and examined the correlations between mental health scores and other associated data.
Results:
A total of 84 TM were included in the analysis. Major depression and generalized anxiety disorder were detected in 14.3% and 3.6%, respectively. Depression severity was negatively associated with age and QoL. Depression and anxiety severity were found to be positively associated.
Conclusions:
Compared with the general Thai population, the prevalence of mental health problems among Thai TM receiving GAHT was higher. Age of maturity may be a potential mental health protective factor, and assessment in younger individuals may benefit mental health.
Keywords: anxiety, major depressive disorder, PHQ-9, quality of life, transmasculine adult, trans men
Introduction
Sexual minorities suffering from mental health problems are at risk because of discrimination, health care inaccessibility, abuse, violence, and gender-specific psychological interventions.1 Compared with the cisgender population, transgender people seem to have more mental health morbidities that significantly improve with gender-affirming therapy.
Depression and anxiety are the most prevalent psychiatric disorders in the transgender population.2 However, variations in the prevalence of psychiatric disorders across countries have been detected. The sociocultural aspect was considered a significant contributing factor to these variations.3
Gender-affirming hormone therapy (GAHT) significantly reduces mental distress and improves quality of life (QoL) in transgender people.4 Nonetheless, there are some conflicting results of GAHT in transmasculine adults or transgender men (TM). TM receiving testosterone may show an increasing prevalence of anger expression, and anger arousal control could be higher for the first 7 months.5
However, this study reported no correlation between serum testosterone levels and anger expression scores. Another long-term prospective study of aggression among TM found no association between aggression and GAHT; however, it found a positive correlation between aggression and anxiety.6
A cross-sectional study from Thailand showed that TM receiving GAHT had adverse overall mental health assessed by the 36-item Short Form Survey (SF-36) questionnaire.7 Poorer bodily pain and overall mental health problems were prevalent among TM currently receiving GAHT.
Compared with TM without GAHT, TM receiving GAHT were eight times more likely to have poorer acceptance by their parents. Moreover, the same study reported no difference in overall mental health problems between Thai transgender women (TW) using GAHT and those who had not received this treatment.7
Furthermore, a study among Thai TW receiving GAHT combined with transfeminizing surgery reported a lower prevalence of depression compared with untreated individuals.8 The incongruity of Thai transgender people's mental health problems needs to be further elucidated.
This study aimed to assess mental health problems among Thai TM receiving GAHT. Standard psychological questionnaires were used to evaluate depression, anxiety, and QoL. Moreover, we analyzed the correlation between mental health and associated factors, including age, weight, height, history of discrimination, gender-affirming surgery, GAHT side effects, testosterone dosage, and serum testosterone levels.
Materials and Methods
Study population
Between February and November 2020, we recruited all patients who were TM, were over 18 years old, and had been diagnosed with gender dysphoria by a psychiatrist at the King Chulalongkorn Memorial Hospital, Thailand. They all received intramuscular injections of 150–250 mg of testosterone enanthate every 2–4 weeks, adjusted by participant serum total testosterone levels.
The target serum testosterone levels were 300–700 ng/dL. All participants received GAHT for at least three consecutive months. Participants who could not read and write in Thai were excluded from the study. Each participant gave written informed consent after we informed them about all the risks and benefits of participating in this study. Demographic and clinical data were also recorded.
Self-report questionnaires were used to evaluate mental health problems. Sample size estimation was calculated based on our previous data. We conducted a pilot study to evaluate the prevalence of major depression among TM at our Gender Health Clinic at King Chulalongkorn Memorial Hospital, Thailand (unpublished data).
Two of 10 TM met the diagnostic criteria for major depression. Based on Wayne's sample size calculation,9 at least 70 participants were required to identify the prevalence of major depression. This study was approved by the Institutional Review Board of Chulalongkorn University (IRB No. 208/2020).
Demographic and clinical data
Demographic data, including age, weight, height, history of discrimination, and sex-affirming surgery, were recorded. Dosage and testosterone levels, as well as their adverse effects, were extracted from medical records.
Thai Patient Health Questionnaire 9
The Thai Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms, including depressed mood, loss of interest and energy, sleep and appetite problems, feeling worthless, trouble concentrating, psychomotor abnormality, and thoughts of death or self-injury.
A PHQ-9 score ≥9 is considered major depression, with sensitivity and specificity of 0.84 and 0.77, respectively.10 Participants screening positive for major depression will be referred to a psychiatrist at the Gender Health Clinic.
Generalized anxiety disorder-7 scale
The Generalized Anxiety Disorder-7 (GAD-7) scale is a brief, self-report screening tool for generalized anxiety disorder and assesses anxiety severity.11 The symptoms measured by the test include feeling nervous, uncontrolled and excessive worrying, trouble relaxing, restlessness, irritability, and feeling afraid that something awful might happen.
A GAD-7 score ≥10 represents a cut point for identifying generalized anxiety disorder, with sensitivity and specificity of 0.89 and 0.82, respectively.11 Participants with positive screening results for generalized anxiety disorder will be referred to a psychiatrist at the Gender Health Clinic.
WHOQOL-BREF-THAI
The WHOQOL-BREF-THAI is a Thai version of the brief World Health Organization Quality-of-Life Scale (WHOQOL-BREF),12 which has 26 items, and is a self-report questionnaire developed to measure four domains related to QoL: physical health, psychological health, social relationships, and environment. Higher scores on the WHOQOL-BREF reflect a higher QoL.
The Thai version of WHOQOL-BREF or WHOQOL-BREF-THAI, translated by Mahatnirunkul et al., showed good validity and reliability,13 and QoL is positively correlated with the test scores.
Statistical analyses
IBM SPSS 22.0 (IBM Corp., Armonk, NY) was used for the analysis. Descriptive statistics were used to report participants' profiles and psychological assessment scores. Bivariate and multivariable logistic regression analyses were used to explore the factors associated with depression. We planned to adjust clinically important covariates, including theoretically associating factors of depression, together with p<0.1 in the bivariate model.
Statistical significance was set at p<0.05. Enter-step elimination was used in the model.
Results
This study's inclusion criteria were met by 84 TM who completed the questionnaire. The mean age was 30.3 years, while the range was 19–46 years. The mean intramuscular dose of testosterone enanthate was 65.1 mg/week. The midway serum testosterone level between injections was 758.5 ng/dL. The duration of GAHT was 24 [7.8, 47.3] weeks (median [interquartile range, IQR]).
Thirty-three participants (40%) had undergone gender-affirming mastectomy; however, none had undergone gender-affirming genital surgery. All TM reported amenorrhea, with the onset of amenorrhea at 5 [4, 8] weeks (median [IQR]). Additionally, all participants reported at least one desirable masculinizing effect of GAHT and 72.6% reported at least one side effect. Social stigmatization was more frequent than stigmatization from peers and family members.
The demographic and clinical data of all the participants and psychological assessment results are presented in Tables 1 and 2, respectively. According to the PHQ-9 scores, 12 participants (14.3%) had major depression and 3 of these also had generalized anxiety disorder (3.6%) according to the GAD-7 scale. Participants' median depression and anxiety scores were 3.0 [1, 6] and 1.0 [0, 4], respectively.
Table 1.
Demographic and Clinical Data (N=84)
| Variables | Results |
|---|---|
| Age (years), mean±SD | 30.3±5.7 |
| Weight (kg), mean±SD | 61.5±11.6 |
| Relationship status, N (%) | |
| Single | 28 (33.3) |
| Couple—living together | 48 (57.2) |
| Couple—living alone | 7 (8.3) |
| Region, N (%) | |
| Bangkok | 59 (70.2) |
| Other provinces | 25 (29.8) |
| Occupation, N (%) | |
| Employee | 62 (73.8) |
| Own business | 14 (16.7) |
| Student | 7 (8.3) |
| Unemployed | 1 (1.2) |
| Income (U.S. dollars per month), N (%) | |
| <300 | 7 (8.3) |
| 300–900 | 58 (69.0) |
| 901–1500 | 17 (20.2) |
| >1500 | 4 (7.1) |
| History of alcohol drinking and smoking, N (%) | |
| No alcohol drinking and smoking | 77 (91.7) |
| Current alcohol drinking and smoking | 2 (2.3) |
| Only smoking | 5 (6) |
| Medical and gender-affirming surgical history, N (%) | |
| Underlying diseasesa | 2 (2.4) |
| Gender-affirming mastectomy | 33 (39.3) |
| Gender-affirming mastectomy with hysterectomy | 5 (5.9) |
| Phalloplasty or metoidioplasty | 0 (0) |
| Dosage of testosterone per week (mg/week), mean±SD | 65.1±19.8 |
| Serum testosterone level (ng/dL) (blood was drawn midway between testosterone enanthate injections), median [IQR] | 693 [502, 934] |
| Duration of GAHT usage (week), median [IQR] | 24 [7.8, 47.3] |
| Amenorrhea rate, N (%) | 84 (100) |
| Side effects of GAHT, N (%) | |
| Alopecia | 42 (50.0) |
| Acne | 79 (94.0) |
| Irritable mood | 29 (34.5) |
| Othersb | 13 (15.5) |
| Onset of masculinizing after GAHT (week), median [IQR] | |
| Skin oiliness/acne | 6 [4, 9.5] |
| Facial/body hair growth | 12 [6, 20] |
| Scalp hair loss | 24 [16, 48] |
| Increased muscle mass and strength | 12[6.5, 20] |
| Amenorrhea | 5 [4, 8] |
| Clitoral enlargement | 10 [5, 16] |
| Vaginal dryness | 6 [4, 12] |
| Deepening of voice | 10 [6, 16] |
| History of discrimination, N (%) | |
| Social | 58 (69.0) |
| Peers | 34 (40.5) |
| Family members | 28 (33.3) |
One participant was diagnosed as having epilepsy, while another had a history of pulmonary tuberculosis.
Other side effects of GAHT included fatigue (N=5), depressed mood (N=4), headache (N=3), breast pain (N=2), anxiety (N=1), vaginal bleeding (N=1), and weight gain (N=1).
GAHT, gender-affirming hormone therapy; IQR, interquartile range; SD, standard deviation.
Table 2.
Mental Health Among Transmasculine Adults Receiving Gender-Affirming Hormone Therapy (N=84)
| 95% CI | ||
|---|---|---|
| Depression | ||
| PHQ-9 total scores, median [IQR] | 3.0 [1, 6] | |
| PHQ-9 score ≥9,a N (%) | 12 (14.3%) | 7.6–23.0 |
| Anxiety | ||
| GAD-7 total scores, median [IQR] | 1.0 [0, 4] | |
| GAD-7 score ≥10,b N (%) | 3 (3.6%) | 0.7–10.0 |
| WHOQOL-BREF-THAI: | ||
| Average quality of life, N (%) | 30 (35.7%) | 25.6–46.9 |
| Good quality of life, N (%) | 54 (64.3%) | 53.1–74.5 |
PHQ-9 score ≥9 is considered major depression.
GAD-7 score ≥10 is considered generalized anxiety disorder.
CI, confidence interval; GAD-7, Generalized Anxiety Disorder-7 scale (min=0 and max=11); PHQ-9, Thai Patient Health Questionnaire 9 (min=0 and max=21); WHOQOL-BREF-THAI, Thai version of the World Health Organization Quality-of-Life-BREF questionnaire.
The prevalence of major depression among TM who had a gender-affirming mastectomy was 18.16%, while it was 11.76% among those who had never had the surgery. We used WHOQOL-BREF-THAI to assess the participants' QoL and it was found that 64.3% and 35.7% had good and average QoL, respectively. Notably, none of the TM had poor QoL.
The correlations between depression and mental health scores are shown in Table 3. We found a positive correlation between PHQ-9 and GAD-7 scores, with a correlation coefficient (R) of 0.804. In comparison, a negative correlation between depression and WHOQOL-BREF-THAI scores was found, with a correlation coefficient (R) of −0.565. The correlation coefficients for the four QoL domains are shown in Table 3.
Table 3.
Pearson's Correlation Coefficients for the Relationship of Depression Scores and Other Mental Health Scores (N=84)
| Variables | PHQ-9 total scores |
|
|---|---|---|
| R | p | |
| GAD-7 total scores | 0.804 | <0.001** |
| WHOQOL-BREF-THAI total scores | −0.565 | <0.001** |
| Total scores of quality-of-life domains | ||
| Physical health | −0.650 | <0.001** |
| Psychological health | −0.565 | <0.001** |
| Social relationships | −0.345 | <0.001** |
| Environmental quality of life | −0.401 | <0.001** |
Correlation is significant at 0.01 (two-tailed).
Table 4 presents a model that evaluates the association between depression severity and contributing factors. The linear regression models demonstrate a positive association between depression severity and anxiety severity, as assessed by the GAD-7 scores (p<0.001). Depression severity was negatively associated with QoL and age (p=0.012 and p=0.004, respectively).
Table 4.
Linear Regression Analysis for the Contributing Factors Associated with Depression Severity (N=84)
| Variables | t | p | Adjusted R2 | F | df | p |
|---|---|---|---|---|---|---|
| Model | 0.690 | 62.574 | 3/80 | <0.001 | ||
| GAD-7 total scores | +9.438 | <0.001* | ||||
| WHOQOL-BREF-THAI total scores | −2.582 | 0.012* | ||||
| Age | −2.943 | 0.004* |
Statistically significant (p<0.05).
In addition, the logistic regression analysis model (Table 5) showed a significant association between major depression and anxiety severity (p=0.003). Major depression was the most significant risk factor for anxiety severity (adjusted odds ratio 1.81; 95% confidence interval 1.23–2.65).
Table 5.
Logistic Regression Analysis for the Contributing Factors Associated with Major Depression (N=84)
| Variables | B | S.E. (B) | p | Adjusted OR | 95% CI of adjusted OR |
|---|---|---|---|---|---|
| Lower–upper | |||||
| GAD-7 total scores | 0.591 | 0.196 | 0.003* | 1.806 | 1.230–2.651 |
| WHOQOL-BREF-THAI total scores | −0.053 | 0.045 | 0.247 | 0.949 | 0.868–1.037 |
| Constant | 0.331 | 4.387 | 0.940 |
Statistically significant (p<0.05).
OR, odds ratio.
Discussion
This study showed a lower prevalence of major depression among Thai TM receiving GAHT than among Western transgender adults (14.3% vs. 47.5–73%).14–16 According to a previous study, the prevalence of major depression in Thai TW is lower than that of their counterparts in Western countries (22.7%).8 Differences in sociocultural factors, discrimination, and stigmatization in the transgender population among countries may be the major determinants of the prevalence of mental problems.
A previous report of six Southeast Asian countries found significant differences in the acceptance rate and tolerance of gender diversity and sexual orientation among those countries. Thailand was considered less likely than Indonesia and Malaysia to reject homosexual attitudes.17 Sociocultural factors should be further investigated as potential mental health protective factors in transgender populations.
However, in this study, the prevalence of major depression among TM was still higher than that of the Thai general population (0.2–2.4%).18,19 The ideal way to verify the effects of GAHT on depression in TM is to compare depression rates in Thai TM receiving GAHT and those who had no hormonal treatment. To the best of our knowledge, there are no available data on depression in Thai TM or Thai trans women who had no GAHT, and further studies are needed.
The prevalence of depression was insignificantly greater among TM who had undergone gender-affirming mastectomy (18.16%) than those who did not (11.76%). However, this might result from selection bias rather than an aftermath of surgery because such a procedure should reduce the mental health burden. Several contributing factors related to depression severity were evaluated in this study.
Some studies have considered aging as a protective factor against depression and mental morbidities.8,20 In contrast, older age was a predictor of depressive disorder or poor mental health.7,21 In this study, we found a significant negative correlation between older age and depression severity. An increase in age represents an extended period of GAHT and other gender-affirming treatments.
As some adverse effects should occur only in the initial phase of GAHT and masculinizing effects continuously accumulate, treatment for TM could reduce distress and improve mental health and depressive symptoms.21,22 Moreover, younger TM might have lower socioeconomic status and a higher risk of discrimination.23 The psychological maturity among older transgender individuals may have strengthened their ability to cope with their gender-associated and other life stressors.24 These findings also support this study's results.
QoL in transgender individuals tends to be poorer compared with the general population. In many studies, gender-affirming therapy, including GAHT, has significantly improved transgender QoL.25–27 The association between QoL and depression has been widely recognized. Discrimination against Thai LGBTQ+ individuals across multiple domains has been demonstrated.28–30 The general attitude toward these populations, including difficulty in health care access, discrimination from their family, marginal employment, and unequal legal system, is considered to have potential negative impacts on their QoL and depression.
GAHT alone might be insufficient to promote mental health or QoL in all TM; therefore, adequate and appropriate support or policy from the government is necessary.31
Gender-affirming treatment for transgender individuals should be considered part of fundamental human rights. Accessibility of treatment through government policies is essential for improving this population's physical and mental health outcomes. Ideally, government coverage for gender-affirming treatment should be considered part of routine health care services. We support Thailand's national policies on LGBTQ+ human rights and inclusion movements.
This study showed a significant positive association between anxiety and depression severity. Although GAHT could reduce anxiety and depressive symptoms, the link between these two psychiatric conditions was limited.25,27 Compared with individuals without generalized anxiety disorder, participants with this psychiatric condition had highly significant differences in scores of depression severity (p<0.001) and QoL (p=0.01).
Comorbid anxiety was considered a poor prognostic factor in patients with major depression.32 TM with higher anxiety levels should be monitored for depression, especially during initiation of GAHT.
Participants in this study revealed that they had more frequent experiences of social stigmatization than from peers or family members. The percentage of TM who experienced social stigmatization was as high as 69% (Table 1). Although Thailand was classified as having a global reputation for being a gender-tolerant country, this study found that the lives of TM were limited by the high percentage of social stigma and discrimination.
Many studies have also reported different forms of stigmatization among individuals with transgender identity. Compared with TM, TW appeared to experience a higher rate of stigmatization issues.33 However, another study34 demonstrated that TM frequently internalize stigmatizing experiences. Stigma at the individual level can affect emotional burden and lead to vulnerable mental health problems in TM.
All TM in this study were prescribed an intramuscular testosterone enanthate preparation for GAHT. The cost-effectiveness of this popular testosterone regimen is the main benefit. However, many studies have mentioned the drawbacks of testosterone enanthate, especially pharmacokinetic issues. A pharmacological study demonstrated that peak testosterone levels occur up to 72 h after injection, followed by a slow decline during the subsequent 1–2 weeks.
Although midway serum testosterone levels between drug injections can represent testosterone concentration, the exact values at the beginning and end of drug injection intervals are different. The peaks and troughs in serum testosterone concentrations that may be associated with fluctuations in emotional symptoms still need to be elucidated.35
Psychological assessment at different time intervals of testosterone administration should be considered, especially in some TM with sensitive responses to hormonal fluctuations. In clinical GAHT practice, dividing the testosterone enanthate dose over a shorter interval can improve and smooth out serum testosterone concentrations.
In contrast, other testosterone regimens, such as intramuscular testosterone undecanoate or transdermal testosterone administration, showed greater consistency and less variability in testosterone concentrations. An individualized approach in the types of testosterone products for particular TM with an adjusted dose to mimic the physiological male testosterone level is the best way to maintain masculinization and minimize the risk of an adverse event.
Further research assessing depression and anxiety of specific types according to the GAHT regimen will provide a more accurate picture of the prevalence of mental disorders in this population.
This study had some limitations. For instance, a causal relationship could not be confirmed because of the study design. Furthermore, although this research site is located in Bangkok, the participants came from rural and urban areas, that is, across the whole country; however, the generalizability of the results of the focused population might be limited because gender-affirming treatment has not yet been covered by national welfare.
TM with economic difficulty who could not access the treatment might not have been enrolled in this study. None of the questionnaires used in our study were specifically designed for the transgender population. Therefore, validated, cultural, and gender-specific psychological tools would benefit future transgender research.
Based on the pharmacokinetics of testosterone enanthate, the testosterone levels increased at the end of the first week after the injection and decreased at the end of the third week. When the psychological test was measured at different time intervals, it may have affected this study's depression and anxiety assessment.
Additional research assessing depression and anxiety at specific times according to the GAHT regimen will provide a more accurate picture of the prevalence of mood disorders in this population.
Conclusions
Compared with the general Thai population, the prevalence of mental health problems among Thai TM receiving GAHT was higher. Age of maturity may be a potential mental health protective factor, and assessment in younger individuals could benefit mental health.
Acknowledgments
The authors would like to acknowledge the support from the Gender Health Clinic staff for collecting data and facilitating the study.
Abbreviations Used
- GAHT
gender-affirming hormone therapy
- GAD-7
Generalized Anxiety Disorder-7
- IQR
interquartile range
- PHQ-9
Patient Health Questionnaire 9
- QoL
quality of life
- SF-36
Short Form Survey
- TM
transgender men
- TW
transgender women
Authors' Contributions
N.P. was involved in conceptualization (lead); data curation; investigation; writing—original draft (lead); formal analysis (lead); and writing—review and editing. A.S. was involved in conceptualization (supporting); writing—original draft (supporting); methodology; formal analysis (equal); and writing—review and editing (equal). K.P. was involved in conceptualization (supporting); supervision; and resources. T.B. was involved in formal analysis (supporting) and writing—review and editing (supporting). S.W. was involved in conceptualization (supporting); writing—original draft (supporting); formal analysis (equal); and writing—review and editing (equal).
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Cite this article as: Pliensak N, Suwan A, Panyakhamlerd K, Bumphenkiatikul T, Wainipitapong S (2023) Mental health of transmasculine adults receiving gender-affirming hormone therapy in Thailand, Transgender Health 8:6, 509–515, DOI: 10.1089/trgh.2021.0160.
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