Impact of Gender-Affirming Interventions on Mental Health and Body Image Satisfaction of Transgender Individuals: A Systematic Review

Abstract

The current systematic review aims to check the impact of gender-affirming interventions (GAIs) on the mental health and body satisfaction of transgender individuals. The literature search was carried out in PubMed, ProQuest, and Scopus, and screening was done based on PRISMA guidelines. Data were extracted using a custom-developed template, and quality assessment was carried out using ROBINS-I and ROB-2. Sixteen studies were finalised for the review. Data were synthesised narratively based on the impact of these GAIs on anxiety, depression, self-harm, and body image satisfaction. Individuals who received the GAIs showed significant improvement in their mental health and body image acceptance. A system of integrative medical, surgical, and psychological interventions for transgender healthcare by incorporating the clinicians, researchers, and policymakers relied on comprehensive evidence on the diverse experiences of transgender individuals. The long-term effects of GAIs remain unclear, underscoring the need for further longitudinal research.

INTRODUCTION

Gender-affirming interventions (GAIs) encompass procedures designed to align an individual’s physical attributes with their gender identity by modifying secondary sexual characteristics.[1] Growing recognition of transgender rights has spurred advancements in healthcare tailored to meet their unique needs, emphasising the potential benefits of GAIs, particularly in mental health and body satisfaction outcomes.[2] Transgender individuals disproportionately face mental health challenges, primarily attributed to stigma, discrimination, and societal marginalisation.[3,4] Additionally, gender dysphoria imposes significant psychological distress, affecting overall well-being.[5,6]

GAIs are increasingly recognised as vital components of transgender healthcare rather than elective or cosmetic procedures.[5] Research indicates that these interventions substantially mitigate gender dysphoria and enhance body satisfaction, contributing to improved mental health outcomes.[7] Hormone therapy, for instance, has been shown to reduce symptoms of depression and anxiety,[8] whilst surgical interventions like chest reconstruction or genital surgeries enhance body satisfaction and alleviate psychological distress.[9]

Nevertheless, the relationship between GAIs, mental health, and body satisfaction remains complex, influenced by individual factors such as age, social support, and pre-existing mental health conditions. Questions regarding the long-term efficacy of these interventions persist, compounded by methodological limitations in existing studies, including small sample sizes and limited longitudinal data.[10,11] A systematic review addressing these gaps is crucial for delineating the impact of GAIs on mental health and body satisfaction. The current systematic review aims to explore the impact of GAIs on the mental health and body image satisfaction of transgender individuals whilst addressing all these research gaps.

MATERIALS AND METHODS

The systematic review adhered to the 2020 PRISMA guidelines to maintain rigorous quality standards.[12] The review protocol and search strategy were registered with PROSPERO under registration number CRD42024586366. A search strategy guided by the PICOS framework was developed, and Table 1 provides the specific details. Using this strategy, two reviewers performed electronic searches across ProQuest, Scopus, and PubMed databases. The search spanned publications from 2014 to 2024, focusing on scholarly English articles involving human participants. MeSH terms were utilised as applicable, and citation tracking was conducted for additional relevant studies. Search terms were applied to identify pertinent articles of titles and abstracts, which were subsequently uploaded to Covidence for further assessment.

Table 1.

Search strategy used for database search and study identification

Participants	Exposure/Interventions	Outcomes
(Transgender individuals OR transmen OR transwoman OR non-binary OR transsexual)	(Medical Interventions OR hormone therapy OR testosterone OR mastectomy OR hysterectomy OR vaginectomy OR metoidioplasty OR phalloplasty OR scrotoplasty OR orchiectomy OR vulvoplasty OR chest masculinisation OR body contouring OR facial feminisation OR breast augmentation OR tracheal shave OR oestrogen OR anti-androgen OR progestogens)	(Psychological Wellbeing OR Depression OR Anxiety OR suicide OR Self-harm OR Body acceptance OR Image satisfaction OR Social support OR Mental health)

Inclusion and exclusion criteria

Studies meeting the following criteria were included: (1) focused on transgender populations, including transmasculine, transfeminine, non-binary, and gender-fluid individuals undergoing GAIs such as hormone therapy or surgery; (2) employed prospective or retrospective cohort designs, randomised controlled trials, quasi-experimental designs, or case-control designs; (3) assessed mental health outcomes, including depression, anxiety, suicide ideation, self-harm, and body satisfaction; and (4) were peer-reviewed studies in English published between August 2014 and July 2024.

Excluded studies included case studies, case series, reviews, editorials, letters, abstracts, conference proceedings, and studies lacking original data. Studies focusing solely on cisgender populations, those combining GAIs with non-specific treatments, or those not measuring mental health outcomes directly related to the intervention were excluded. Studies with a high or critical risk of bias (ROB) were also omitted.

Study selection

Two reviewers independently screened and selected studies based on the criteria. Discrepancies were resolved through discussions with the corresponding author. The PRISMA guidelines were followed, as illustrated in Figure 1. Two reviewers conducted data coding and extraction independently, with disagreements resolved through discussion.

Figure 1.

PRISMA flow diagram of study identification process

Data extraction and risk of bias assessment

Two independent reviewers extracted data from the identified studies based on the custom-developed data extraction template using the Covidence. Deprecencies were resolved through discussion with the corresponding author. Details are given in Table 2. The “Risk of Bias in Non-randomised Studies – of Interventions (ROBINS-I)” tool was applied to non-randomised studies,[13] whilst the ROB 2 tool was used for randomised studies[14] for the quality assessment, and details are given in Tables 3 and 3a. Discrepancies in bias assessments were resolved via consultation with the corresponding author.

Table 2.

Data extraction from identified studies

Study reference and Location	Study design, sample size, and duration	Population	Exposure/Intervention	Outcome measure	Significant results/Conclusions
Morssinkhof et al., 2024[23] Netherlands	Design: Prospective cohort research design Sample size: 199 Duration: January 2020 – August 2022	Transgender individuals who were about to start gender-affirming hormone therapy.	Gender-affirming hormone therapy (GAHT) – (Testosterone and Oestradiol)	Mini-International Neuropsychiatric Interview (MINI+) Inventory of Depressive Symptomatology-Self Report (IDS-SR).	In the first follow-up, transmasculine participants saw a significant 16% temporary improvement in lethargy-related symptoms but no major changes in IDS-SR scores, anxiety, or somatic symptoms. After 12 months, transfeminine participants experienced a significant 24% increase in mood-related symptoms, whilst transmasculine participants showed no notable mood changes.
Aldridge et al, 2023[21] United Kingdom	Design: Prospective cohort research design Sample size: 137 Duration: November 2014 – March 2018	Transgender individuals underwent Gender-affirming hormone therapy (GAHT).	Gender-Affirming Hormone Therapy (GAHT)	Gender Congruence Life Satisfaction Scale Hospital Anxiety and Depression Scale (HADS).	The study did not report any statistically significant differences in anxiety and depression levels between T0 (pre-treatment) and T1 (post-treatment) assessments. The mean life satisfaction scores for those with and without anxiety at the follow-up assessment were not significantly different. The mean life satisfaction scores for those with and without depression at the follow-up assessment also showed no significant difference.
Chen et al., 2023[18] United States	Design: Prospective cohort research design Sample size: 315 Duration: July 2016 to June 2019	Transgender and non-binary youth aged 12-20 receiving gender-affirming hormone interventions.	Gender-affirming hormone therapy (GAHT)/Gonadotropin-releasing hormone (GnRH) therapy	Transgender Congruence Scale Beck Depression Inventory-II Revised Children’s Manifest Anxiety Scale (Second Edition) Positive affect and life satisfaction measures from the NIH Toolbox Emotion Battery.	Improvement in appearance congruence, positive affect, and life satisfaction. Enhanced overall well-being. An average annual decrease of 1.27 points on the BDI-II. Among participants with severe depression scores at baseline, 67% reported scores in the minimal or moderate ranges at 24 months. Likewise, 64% of those with moderate depression scores at baseline improved to minimal or moderate ranges by the study’s end with statistical significance. Participants reported lower anxiety scores, whilst most of the participants moved from the clinical levels of anxiety to normal levels during the course of the study.
Nolan et al., 2023[25] Australia	Design: Randomised controlled trial Sample size: 64 Duration: November 2021 - July 2022	Experimental group: Transgender individuals who receive immediate testosterone therapy. Control group: Transgender individuals who have a waiting period of 3 months before the commencement of testosterone therapy.	Gender-Affirming Hormone Therapy (GAHT) – (Testosterone)	Gender Preoccupation and Stability Questionnaire (GPSQ) Patient Health Questionnaire-9 (PHQ-9) Suicidal Ideation Attributes Scale (SIDAS).	The study revealed that testosterone therapy significantly alleviated gender dysphoria. The trial also showed that testosterone therapy was linked to reductions in both depression and suicidality among transgender and gender-diverse adults.
Chaovanalikit et al., 2022[28] Thailand	Design: Prospective cohort research design Sample size: 37 Duration: January 2018 - December 2020	Individuals diagnosed with gender dysphoria by two expert psychiatrists based on DSM-5 and ICD-11 criteria.	Gender-affirming surgery (GAS) – (including Vaginoplasty)	WHO Quality of Life Brief Questionnaire in Thai Rosenberg Self-Esteem Scale Patient Health Questionnaire-9.	Noted significant improvement in the QoL, specifically in domains of psychological and social relationships and sexual relationships in the post-surgical assessment. Significant improvement in self-esteem among the participants in the post-surgical assessments. Identified a significant decrease in depression levels postoperatively. Before surgery, 13.5% of participants had mild depression, but none reported depressive symptoms afterward.
Tordoff et al., 2022[20] United States	Design: Prospective cohort research design Sample size: 104 Duration: August 2017 – June 2018	Transgender and non-binary youth receiving gender-affirming hormone therapy.	Gender-affirming hormone therapy (GAHT)	Patient Health Questionnaire 9-item scale (PHQ-9) Generalised Anxiety Disorder 7-item scale (GAD-7).	Youths who received GAHT had 60% lower odds of moderate to severe depressive symptoms compared to those who did not. GAHT was linked to a 73% reduction in the odds of self-harm or suicidal thoughts. Youths who did not receive puberty blockers or gender-affirming hormones showed 2 to 3 times higher levels of depressive symptoms and suicidality. No statistically significant improvements in anxiety scores among the participants.
Aldridge et al., 2021[22] United Kingdom	Design: Prospective Cohort research design Sample: 178 Duration: November 2014 – March 2018	Transgender and non-binary individuals underwent gender-affirming hormone treatment (GAHT).	Gender-affirming hormone therapy (GAHT)	Hospital Anxiety and Depression Scale.	The study found significant reductions in depression and anxiety symptoms after 18 months of GAHT when compared with the baseline assessment.
Achille et al., 2020[15] United States	Design: Prospective cohort research design Sample: 50 Duration: December 2013 –December 2018	Transgender youth receiving gender-affirming hormone therapy (GAHT).	Gender-affirming hormone therapy (GAHT) - (Puberty blockers and Endocrine)	Centre for Epidemiologic Studies Depression Scale (CESD-R) Patient Health Questionnaire Modified for Teens (PHQ-9) Quality of Life Enjoyment and Satisfaction Questionnaire (QLES-Q-SF).	The study identified a significant reduction in depression scores and suicidal ideation over time. Improvement was noted in quality of life (QoL), particularly in male-to-female (MTF). Effect sizes were more significant for MTF than for female-to-male (FTM) participants.
Cantu et al., 2020[17] United States	Design: Prospective cohort research design Sample size: 80 Duration: September 2017–June 2019	Transgender and gender nonconforming (TGN) youth who attended an academic medical centre located in the North-western United States.	Gender-affirming hormone therapy (GAHT)	Patient Health Questionnaire - 9 (PHQ-9) Generalised Anxiety Disorder – 7 (GAD-7).	The study identified that there is no significant difference in the average depression and anxiety scores between the baseline and post-intervention.
Kuper et al., 2020[19] United States	Design: Prospective cohort research design Sample size: 148 Duration: August 2014 – March 2018	Transgender youth aged between 9 and 18 who received gender-affirming hormone therapy as part of a multidisciplinary programme.	Gender-affirming hormone therapy (GAHT)	Body Image Scale (BIS) Screen for Child Anxiety Related Emotional Disorders (SCARED) Quick Inventory of Depressive Symptoms (QIDS).	There was a significant improvement in body dissatisfaction, self-reported depressive symptoms, and anxiety symptoms in the follow-up assessments. Significant decrease in anxiety among the participants. There was a noticeable increase in passive suicidal ideation, suicide attempts, and non-suicidal self-injury in the follow-up period.
Papadopulos et al., 2020[27] Germany	Design: Retrospective cohort research design Sample size: 69 Duration: 2007 – 2013	Transgender women who had received gender-confirming treatment (GCT) through a combined vaginoplasty technique.	Gender-affirming surgery (GAS) – (Vaginoplasty)	Patient Health Questionnaire 4 (PHQ-4) Freiburg Personality Inventory, Revised (FPI-R) Rosenberg Self-esteem Scale (RSES).	There was significant statistical difference was identified in the scores of anxiety and depression in the final assessment when compared with the baseline assessment.
Allen et al., 2019[16] United States	Design: Prospective Cohort research design Sample size: 47 Duration: 3 years	Transgender individuals who received gender-affirming hormone therapy (GAH) as part of their treatment for gender dysphoria at the Children’s Mercy Hospital Gender Pathway Services (GPS) clinic.	Gender-affirming hormone therapy (GAHT)	Centre for Epidemiologic Studies Depression Scale (CESD-R) Patient Health Questionnaire Modified for Teens (PHQ-9) Quality of Life Enjoyment and Satisfaction Questionnaire (QLES-Q-SF).	After the GAHT, the patients’ suicidality decreased significantly from the pre-test to the final assessment. Participants’ general well-being scores significantly increased from the pre-test to the final assessment. Improvement was noted in the depressive scores in the post-exposure assessment.
Fallahtafti et al., 2019[26] Iran	Design: Quasi-experimental research design Sample size: 66 Duration: 2016 -2017	Transgender including transmen and transwomen individuals undergo gender-affirming surgical interventions.	Gender-affirming surgery (GAS)	Oxford Happiness Questionnaire (OHQ) Symptom Check List (SCL-25).	Pre-operative and post-operative transgender individuals showed a significant improvement in happiness, with post-operative individuals reporting higher levels of happiness. There was a significant improvement in mental health scores between pre-operative and post-operative transgender individuals. There were significant improvements in mean scores for somatisation, anxiety, depression, interpersonal sensitivity, phobia, obsession-compulsion, paranoia, and psychosis.
Van de Grift et al., 2017[29] Netherlands, Belgium, and Germany.	Design: Prospective cohort research design Sample size: 201 Duration: 2007 – 2015	Individuals seeking gender-confirming medical interventions in gender identity clinics in Amsterdam, Ghent, and Hamburg.	Gender-affirming hormone therapy (GAHT) and gender-affirming surgery (GAS)	Utrecht Gender Dysphoria Scale (UGDS) Body Image Scale for Transsexuals (BIS).	Participants who underwent gender-affirming medical interventions reported significantly lower gender dysphoria at follow-up compared to their baseline assessment, in contrast to those who did not receive any interventions. Participants receiving both hormone therapy and surgery showed notable improvements in body satisfaction at follow-up compared to baseline scores.
Fisher et al., 2016[31] Italy	Design: Multidisciplinary prospective design Sample size: 54 Duration: 2 years	Individuals experiencing gender dysphoria.	Gender-affirming hormone therapy (GAHT)	Body Uneasiness Test (BUT) Symptom Checklist 90 Revised (SCL-90-R) Gender Identity/Gender Dysphoria Questionnaire (GIDYQ-AA) Beck Depression Inventory (BDI) II.	Participants who underwent medical interventions reported reduced levels of gender dysphoria compared to baseline. Individuals who received both hormone therapy and surgery experienced significantly lower gender dysphoria compared to those without medical interventions. There was no significant difference in gender dysphoria between the ‘hormones only’ group and the ‘no-intervention’ group. Overall, body dissatisfaction scores were significantly reduced at follow-up compared to admission. Participants who underwent medical interventions demonstrated improvements in psychological functioning.
Van de Grift et al., 2016[24] Netherlands	Design: Prospective cohort research design Sample size: 26 Duration: September 2014 – June 2015	Transmen undergoing mastectomy at VU University Medical Centre in Amsterdam, The Netherlands.	Gender-affirming surgery (GAS)	Appearance Schemas Inventory-Revised Body Image Quality of Life Inventory (BIQLI) Body Image Scale for Transsexuals Multidimensional Body-Self Relations Questionnaire Rosenberg Self-esteem Scale Situational Inventory of Body Image Dysphoria Perceived Effect of Surgery	Individuals reported significant improvement in body image satisfaction in the post-surgical assessment compared to the baseline assessment. Body image is directly linked to better quality of life and higher self-esteem. The overall BIQLI score showed no significant change post-surgery, but participants reported a notable improvement in how body image contributed to life satisfaction and self-worth.

Table 3.

Risk of Bias (Quality) Assessment Using ROBINS-I

Study Reference	Bias due to confounding	Bias in the selection of participants	Bias in the classification of interventions	Bias due to deviations from intended interventions	Bias due to missing data	Bias in the measurement of outcomes	Bias in the selection of the reported result	Overall bias
Morssinkhof et al., 2024[23]	Low	Low	Low	Low	Moderate	Moderate	Moderate	Moderate
Aldridge et al, 2023[21]	Low	Low	Low	Low	Moderate	Serious	Serious	Serious
Chen et al., 2023[18]	Low	Low	Low	Low	Low	Moderate	Moderate	Moderate
Chaovanalikit et al., 2022[28]	Moderate	Low	Low	Low	Low	Moderate	Low	Moderate
Tordoff et al., 2022[20]	Moderate	Low	Low	Low	Low	Moderate	Moderate	Moderate
Aldridge et al., 2021[22]	Moderate	Low	Low	Low	Moderate	Moderate	Moderate	Moderate
Achille et al., 2020[15]	Low	Low	Low	Low	Low	Moderate	Moderate	Moderate
Cantu et al., 2020[17]	Moderate	Low	Low	Low	Low	Moderate	Low	Low
Kuper et al., 2020[19]	Moderate	Low	Low	Low	Low	Moderate	Moderate	Moderate
Papadopulos et al., 2020[27]	Moderate	Low	Low	Low	Low	Moderate	Serious	Serious
Allen et al., 2019[16]	Low	Low	Low	Low	Low	Moderate	Moderate	Moderate
Fallahtafti et al., 2019[26]	Moderate	Low	Low	Low	Low	Moderate	Serious	Serious
Van de Grift et al., 2017[29]	Low	Low	Low	Low	Low	Moderate	Moderate	Moderate
Fisher et al., 2016[31]	Low	Low	Low	Low	Low	Moderate	Moderate	Moderate
Van de Grift et al., 2016[24]	Moderate	Low	Low	Low	Low	Moderate	Serious	Serious

Table 3a.

Risk of Bias (Quality) Assessment using ROB-2

Study reference	Risk of bias arising from the randomisation process	Risk of bias due to deviations from the intended interventions	Risk of bias due to missing outcome data	Risk of bias in the measurement of the outcome	Risk of bias in the selection of the reported result	Overall risk of bias
Nolan et al., 2023[25]	Some concerns	Low	Low	Some concerns	Low	Some concerns

RESULTS

Study characteristics

Sixteen studies were included in the review, encompassing 1,791 participants. The sample size in each study ranged from 26 to 315 participants. Out of the 16 selected studies, six were conducted in the United States,[15,16,17,18,19,20] two were conducted in the United Kingdom,[21,22] and two were conducted in the Netherlands.[23,24] Remaining studies were conducted in Australia,[25] Iran,[26] Germany,[27] Thailand,[28] and in multiple centres (Netherlands, Belgium, and Germany).[29] The majority of the studies were conducted in developed countries. Thirteen studies employed a prospective cohort research design, whilst three studies utilised retrospective cohort, randomised controlled trial, and quasi-experimental designs, respectively.

The mean age of the participants ranged from 14.39 years[21] to 36.4 years.[29] In 11 studies (68.75%), the primary intervention was gender-affirming hormone therapy (GAHT), whilst four (25%) studies focused on gender-affirming surgery (GAS) as the intervention. One study (6.25%) provided a combination of both interventions. The results of the review were categorised and narratively synthesised based on their impact on depression, anxiety, self-harm, and body image satisfaction.

Depression

Depression is recognised as one of the most prevalent mental health issues among the transgender and non-binary population.[30] Fourteen studies (87.5%) assessed self-reported depression outcomes among transgender individuals, with data collected from 1,564 participants (ranging from 47 to 315 participants per study). Of these, 11 studies (68.75%) reported depression outcomes following GAHT, whilst the remaining three studies reported outcomes after GAS.

In the 12-month follow-up study where participants received GAHT, transfeminine participants experienced a 24% improvement in mood-related symptoms, whilst transmasculine participants showed no notable changes in mood.[23] In the study where GAHT/gonadotropin-releasing hormone (GnRH) therapy was provided as the intervention, it reported that along with an annual decrease of 1.27 points in Beck Depression Inventory-II, 67% of participants with severe depression and 64% with moderate depression improved to moderate or mild levels within a 24-month follow-up period.[18] Chaovanalikit et al.[28] found that in the post-GAS assessment, none of the participants reported depressive symptoms, whereas five out of 37 (13.6%) had reported mild depressive symptoms before the intervention, with a statistically significant improvement of 99% (P < 0.01). In the pre-intervention assessment, 40.3% (n = 54) of transgender and non-binary (TNB) youth scored above the threshold, indicating a possible depressive disorder (scores of 8–10), and 21.64% (n = 29) scored above the threshold for a probable depressive disorder (scores of 11 or higher). However, in the post-GAHT follow-up, participants reported 60% lower odds of experiencing moderate to severe depression.[20]

Similarly, Aldridge et al.[22] found that, compared to a mean baseline depression score of 7.24 ± 4.03, the 18-month follow-up after GAHT showed a reduction in the mean depressive score from 2.72 to 1.38, with a statistical significance of 99% (P < 0.01). The follow-up assessment after GAS revealed a significant statistical difference in self-reported depression scores compared to the pre-GAS assessment.[26,27] Allen et al. identified a significant improvement in the depression scores of the participants in the post-exposure assessment.[16] For transmasculine individuals, depression levels were significantly lower in the GAHT group compared to the non-GAHT group (P = 0.027), whilst for transfeminine individuals, the difference in depression levels between the GAS and non-GAS groups did not reach statistical significance.[31]

Anxiety

Anxiety among transgender individuals is often attributed to a lack of social acceptance and body incongruence. Eight studies (50%) assessed anxiety as a variable whilst evaluating the impact of GAIs on TNBs, with outcomes recorded from 1,227 participants (n = 66-315). All studies that evaluated changes in anxiety used GAHT as the exposure measure.

Four of the studies followed patients for an average period of 12 months,[19,20,23,26] whilst six studies conducted only a single follow-up assessment after the intervention exposure, and one study carried out four follow-up assessments.[18] Six out of eight studies reported significant improvements, whilst two remaining studies reported noticeable changes in the post-intervention assessment.

Two studies included children and adolescents who underwent GAHT,[18,19] with most of the studies carried out with TNB youth and adult participants. Two studies specified that the participants were administered GnRH therapy[18] and testosterone and oestradiol[23] as the GAHT, whilst the remaining studies did not mention the details. Only 50% of studies reported a significant improvement in anxiety in the post-intervention assessment.

TNB youth aged 12–20 receiving GAHTs reported an annual decrease in anxiety scores of 1.46 points (95% confidence interval [CI]: −2.13 to − 0.79) over two years, and 38.5% of participants with baseline anxiety scores in the clinical range (T scores >60) improved to the nonclinical range in 24 months.[18] In an 18-month follow-up study with TNBs, a slight reduction in anxiety symptoms was observed after 18 months of GAHT.[22] A study incorporating transgender youth identified that in the post-intervention assessment, noticeable improvement in generalised, separation, and school-related anxiety symptoms was observed at the follow-up assessment (P < 0.05),[19] and significant improvement was noted in the anxiety scores in the post-intervention assessment.[26]

It is identified that in the post-intervention assessments, no significant changes in anxiety symptoms after GAHT were reported.[23] Tordoff et al.[20] reported that an adjusted odds ratio (aOR) for anxiety of 1.01, with a 95% CI of 0.41 to 2.51, indicating no statistically significant improvements in anxiety scores among participants who received GAHT. Similarly, Cantu et al.[17] and Aldridge et al.[21] identified no significant difference between the pre and post-exposure follow-up assessment anxiety scores.

Self-harm

The prevalence of suicidality and non-suicidal self-injury (NSSI) is found to be higher among TNB individuals.[32] The review found that only one study assessed the impact of GAIs on suicidality and NSSI as the primary outcome measure.[25] However, several studies reported on the impact of GAIs on suicidality and NSSI as secondary outcomes.

Nolan et al.[25] identified that testosterone therapy was directly linked to a reduction in suicidality among TNBs. GAHT was linked to a 73% reduction in the odds of self-harm or suicidal thoughts, whilst youths who did not receive puberty blockers or gender-affirming hormones displayed 2 to 3 times higher levels of suicidality.[20] Additionally, it is identified that transgender youth who received GAHT showed a significant reduction in suicidal ideation over time.[15] Similarly, suicidality had been reduced among children with gender dysphoria, followed by the administration of puberty blockers.[16]

In contrast, there was a noticeable increase in passive suicidal ideation, suicide attempts, and NSSI among children experiencing gender dysphoria who received GAHT during the post-intervention follow-up period.[19]

Body image satisfaction

Four studies prospectively assessed the body image satisfaction of TNBs after GAIs, and outcomes were recorded from 429 participants (n = 26-201). Three studies used the body image scale to assess body image satisfaction,[19,29,31] and Van De Grift et al.[24] used the revised Appearance Schemas Inventory. The transgender individuals showed significant improvement in body image satisfaction (Baseline = 69.9 to post-intervention = 51.7), with no significant difference in the scores of affirmed males and females.[19] Another study showed decreased levels of body dissatisfaction among participants in the post-intervention follow-up assessment, and dissatisfaction with sexual organs was highest in the no-intervention group.[29] Similarly, increased levels of bodily satisfaction were identified among the participants after the post-intervention follow-up, and a significant reduction in general body uneasiness was observed (time effect: Transmasculine: b = 0.24, P < 0.001; transfeminine: b = 0.24, P < 0.001), with a more substantial impact in transfeminine individuals (F = 19.70, P < 0.001).[31] Following GAS, transgender individuals reported a significant improvement in body image satisfaction compared to baseline, with body image being directly linked to better quality of life (QoL) (r = −0.448, P ≤ 0.01) and self-esteem (r = 0.716, P ≤ 0.001).[24]

Risk of bias (quality) assessment

The quality assessment classified studies as “Low,” “Moderate,” “Severe,” and “Critical” for non-randomised studies and “Low,” “High,” or “Some concerns” for RCTs based on the transparency of information presented in the articles. The ROBINS – I identified that ten studies were identified as having moderate bias,[15,16,18,19,22,23,28,29,31] four studies with serious bias,[21,24,26,27] and one study was found to have low bias.[17] The study was assessed using ROB-2 and rated as having some concerns.[25] Details of the ROB assessment were documented in detail in Tables 3 and 3a.

DISCUSSION

The systematic review synthesised 16 studies conducted between 2014 and 2024, assessing the impact of GAIs on mental health and body satisfaction among transgender individuals. Most studies evaluated the effects of GAHTs, with some exploring surgical interventions. Prospective cohort designs predominated, whilst randomised controlled trials (RCTs), quasi-experimental, and retrospective designs were limited. The findings broadly indicate that GAIs improve mental health and body satisfaction. GAHT was associated with reductions in depression, anxiety, and suicidality. Surgical interventions yielded positive outcomes for mental health, gender dysphoria, body satisfaction, and self-esteem.

The review identified that GAHT can reduce depression and improve body image satisfaction among transgender individuals, whilst the impact on anxiety is showing mixed results. The findings of the review are consistent with the findings of the existing reviews, which checked the improvement of depression following GAHT.[33,34] The improvement in depression can be linked to the improvement in gender dysphoria among transgender individuals after GAHT. Similarly, it is identified that GAS is associated with improvement in depression and body image satisfaction, which is also consistent with the findings of the existing reviews, which identified that GAS has a positive effect on the mental health and QoL of transgender individuals.[35]

Despite these findings, the studies exhibited moderate to severe risks of bias, including small sample sizes and inadequate confounding control, consistent with earlier reviews.[10,36,37] Few studies qualitatively assessed the subjective impact of GAIs, underscoring the need to explore cultural, procedural, and psychosocial factors influencing mental health.[38,39] Understanding lived experiences can guide tailored interventions and ensure comprehensive care.[37]

Whilst GAIs address gender dysphoria, they alone may not fully mitigate mental health challenges, as other factors—family support, societal acceptance, discrimination, and access to safe spaces—critically shape outcomes.[40,41] For instance, social affirmation, such as gender identity disclosure, is linked to reduced depression and NSSI.[6,42] Future studies should consider these psychosocial factors alongside GAIs to optimise mental health interventions.

GAIs effectively reduce depressive symptoms. GAHT consistently demonstrated significant decreases in depression.[7,34,36] Longitudinal studies reported sustained improvements, with some identifying reduced depressive cognitions 12 months post-intervention.[43] However, paediatric populations showed inconsistent outcomes, and most studies relied on observational designs, limiting causality exploration. Social and environmental factors, such as support systems and living environments, further influence depressive outcomes. Experimental studies are needed to establish the interplay between GAIs and these factors.

The impact of GAIs on anxiety is inconclusive. Approximately half of the studies reviewed reported reductions in anxiety post-intervention,[34,44] whilst the remainder found no significant effects. For example, transmasculine individuals reported reduced anxiety after testosterone therapy, whilst anxiety levels among transfeminine individuals remained stable.[45] Other studies highlighted the predictive role of diagnosable anxiety in seeking GAIs.[46] Conversely, puberty blockers showed no effect on anxiety despite improving other psychopathologies.[47] Future research must account for confounding factors like social support and resilience to clarify these relationships.

GAIs show promise in reducing suicidality and NSSI. Most studies reported decreased suicidality following GAIs, including reduced risks after GAHT and surgical interventions.[1,48] Puberty blockers also demonstrated reductions in suicidal tendencies in adulthood.[49] These improvements reflect reduced gender dysphoria, enhanced self-acceptance, and social integration post-intervention.[5] However, the lack of RCTs and short follow-up periods limits the generalizability of these findings. Comprehensive mental health support and personalised care are crucial for individuals with pre-existing psychological conditions or insufficient social networks.

GAIs significantly enhance body satisfaction, alleviating psychological distress related to physical incongruence. GAHT and surgical interventions improved body image satisfaction.[50,51] Studies found that individuals who underwent GAIs exhibited higher body satisfaction than those awaiting interventions.[52] Factors such as intervention type, pre-existing mental health, and individual expectations moderated these benefits.[53] The lack of long-term follow-up studies underscores the need to evaluate sustained outcomes, considering ageing, cultural norms, and societal perceptions.

Even though the study is supported by its profound methodological approach based on the PRISMA guidelines, it has several limitations. The findings of this study should be interpreted given the moderate to severe ROB, with issues such as small sample size and inadequate control of confounding factors, which affect the robustness of the findings. Also, included studies had only limited follow-up assessment, which can hinder the long-term effects of GAIs on mental health and body image satisfaction. Also, the review excluded studies other than English, which could have omitted potential studies published in different languages. Another major limitation of this review is the inability to perform a meta-analysis due to considerable variability in study designs, interventions, outcome measures, and follow-up durations among the included studies.

Clinical implication

The review indicates that GAIs are associated with significant improvements in mental health outcomes. Clinicians should incorporate GAIs as vital components of transgender healthcare to reduce depression, anxiety, and gender dysphoria. However, given the variability in individual responses and unclear long-term effects, personalised care plans and ongoing monitoring are essential. Clinicians must consider pre-existing mental health conditions and social support systems, ensuring comprehensive, multidisciplinary approaches to optimise psychological well-being and overall QoL for transgender patients

CONCLUSION

This systematic review provides an in-depth analysis of how GAIs affect the mental health and body satisfaction of TNB individuals. The evidence strongly supports that GAIs improve mental health and body satisfaction by significantly reducing gender dysphoria and alleviating depression and anxiety, thus aligning physical appearance with gender identity and enhancing psychological well-being. However, the review highlights the complex and variable outcomes of GAIs. The long-term effects of GAIs remain unclear, underscoring the need for further longitudinal research.

The review underscores the necessity of a personalised approach to transgender healthcare, integrating both medical and psychological support as demand for gender-affirming care increases; clinicians, researchers, and policymakers need to rely on comprehensive evidence that considers the diverse experiences of transgender individuals. Future research should address methodological limitations, such as small sample sizes, short follow-up periods, and lack of diversity in study populations, to better understand the long-term effects of GAIs and ensure effective and compassionate care.

Author contributions

We declare that the authors have no competing interests, and all the authors listed below have provided significant contributions, and read and approved the manuscript.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)

We hereby declare that the authors used the AI tool Grammarly for grammar and spelling correction and paraphrasing purposes to improve readability.

Funding Statement

Nil.