Abstract
This survey study examines the association between acne and mental health outcomes for transmasculine persons who have received testosterone.
Mental health problems, including symptoms of anxiety and depression, are common among transgender persons.1 Gender-affirming hormone therapy (HT) may improve depression and anxiety in transgender persons who are experiencing gender dysphoria.1 Masculinizing HT with testosterone is associated with moderate-to-severe acne development in transmasculine (TM) persons.2 While acne is associated with depression and anxiety in the general population, to our knowledge, the association between acne and mental health outcomes and body-gender congruence in the context of HT remains unknown.3
Methods
This study was approved by the Emory University institutional review board, and written informed consent was provided electronically. It aimed to assess the association between moderate-to-severe acne and mental health outcomes in TM persons who have received testosterone and were enrolled in the multicenter cohort Study of Transition, Outcomes and Gender (STRONG).2,4 Of 2136 eligible transgender participants, 696 (33%) completed the survey, 346 (16.2%) identified as TM, and 283 (13.2%) reported testosterone use and responded to acne-related questions. The exposure variable was defined as self-reported moderate-to-severe acne (pimples) as diagnosed by a physician, with response options of never, current, and past. Outcomes of clinically significant depression and anxiety were defined as a score of 10 or greater on the 10-item Center for Epidemiologic Studies Depression Short Form and a score of 22 or greater on the 21-item Beck Anxiety Inventory, respectively.4 The outcome of high body-gender congruence was defined as a median or above score in the 15-item Transgender Congruence Scale.4 Demographic and outcome variables were compared across moderate-to-severe acne diagnosis categories using χ2, Fisher exact, or Kruskal-Wallis tests. Multivariable logistic regression models were used to adjust for age, race/ethnicity, gender-affirming surgery status, education, and income. Statistical analyses were performed using SAS, version 9.4 (SAS Institute), with P < .05 in 2-sided tests considered significant.
Results
Among 283 TM persons receiving testosterone, 188 (66.4%) reported never having acne, 49 (17.3%) reported past acne, and 46 (16.3%) reported current acne (Table 1). The median age was 31 years (interquartile range, 24-40 years). A total of 133 (47%) and 59 TM persons (21%) reported clinically significant depression and anxiety symptoms, respectively. Dichotomized depression and anxiety outcomes differed by moderate-to-severe acne diagnosis (Table 2), as did continuous depression and anxiety scores (data not shown). Current moderate-to-severe acne was associated with a greater likelihood of mental health symptoms, with adjusted odds ratios of 2.4 (95% CI, 1.1-5.4) and 2.7 (95% CI, 1.2-6.3) for depression and anxiety, respectively.
Table 1. Demographic Characteristics of TM Survey Respondents Who Had Received Gender-Affirming Therapy and Reported Acne Status.
| Characteristic | Reported acne, No. (%) | P value | ||
|---|---|---|---|---|
| Never (n = 188) | Past (n = 49) | Current (n = 46) | ||
| Age at time of survey, y | ||||
| 18-24 | 37 (19.7) | 9 (18.4) | 27 (58.7) | <.001 |
| 25-34 | 66 (35.1) | 23 (46.9) | 10 (21.7) | |
| 35-44 | 44 (23.4) | 9 (18.4) | 4 (8.7) | |
| ≥45 | 41 (21.8) | 8 (16.3) | 5 (10.9) | |
| Race/ethnicity | ||||
| Non-Hispanic | .32 | |||
| White | 101 (53.7) | 36 (73.5) | 30 (65.2) | |
| Black | 8 (4.3) | 2 (4.1) | 1 (2.2) | |
| Asian/Pacific Islander | 17 (9.0) | 3 (6.1) | 1 (2.2) | |
| Hispanic | 38 (20.2) | 5 (10.2) | 8 (17.4) | |
| Mixed, other, or unknown | 24 (12.8) | 3 (6.1) | 6 (13.0) | |
| Education | ||||
| High school graduate or less | 24 (12.8) | 5 (10.2) | 11 (23.9) | .01 |
| Some college, associate, or technical school | 56 (29.8) | 9 (18.4) | 17 (37.0) | |
| College graduate or greater | 56 (29.8) | 18 (36.7) | 13 (28.3) | |
| Graduate/professional school | 46 (24.5) | 17 (34.7) | 3 (6.5) | |
| Missing | 6 (3.2) | 0 (0.0) | 2 (4.4) | |
| Income, $ | ||||
| <25 000 | 32 (17.0) | 15 (30.6) | 11 (23.9) | .01 |
| 25 000-49 999 | 36 (19.2) | 9 (18.4) | 11 (23.9) | |
| 50 000-74 999 | 44 (23.4) | 7 (14.3) | 4 (8.7) | |
| 75 000-99 999 | 29 (15.4) | 6 (12.2) | 5 (10.9) | |
| ≥100 000 | 30 (16.0) | 10 (20.4) | 3 (6.5) | |
| Missing | 17 (9.0) | 2 (4.1) | 12 (26.1) | |
| Gender-affirming therapy | ||||
| Hormone only | 47 (25.0) | 4 (8.2) | 15 (32.6) | .02 |
| Chest surgery without genital surgerya | 77 (41.0) | 27 (55.1) | 21 (45.7) | |
| Genital surgery with or without chest surgerya | 64 (34.0) | 18 (36.7) | 10 (21.8) | |
Abbreviation: TM, transmasculine.
Chest surgery referred to any history of mastectomy or breast augmentation, and genital surgery referred to any history of hysterectomy, orchiectomy, vaginectomy, and/or vaginoplasty.
Table 2. Presence of Acne and Associated Mental Health Outcomes in TM Patients.
| Characteristic | Acne status for TM respondents, No (%)a | P value | ||
|---|---|---|---|---|
| Never | Past | Current | ||
| Depression score | ||||
| ≥10b | 73 (40.3) | 23 (50.0) | 32 (71.1) | .001 |
| <10b | 108 (59.7) | 23 (50.0) | 13 (28.9) | |
| Odds ratio (95% CI) | 1 [Reference] | 1.5 (0.8-2.8) | 3.6 (1.8-7.4) | |
| Adjusted odds ratio (95% CI)c | 1 [Reference] | 1.5 (0.7-3.0) | 2.4 (1.1-5.4) | |
| Anxiety score | ||||
| >21d | 27 (15.6) | 10 (22.7) | 18 (39.1) | .002 |
| ≤21d | 146 (84.4) | 34 (77.3) | 28 (60.9) | |
| Odds ratio (95% CI) | 1 [Reference] | 1.6 (0.7-3.6) | 3.5 (1.7-7.1) | |
| Adjusted odds ratio (95% CI)c | 1 [Reference] | 2.1 (0.8-5.1) | 2.7 (1.2-6.3) | |
| TCS score | ||||
| ≥Mediane | 95 (51.9) | 29 (61.7) | 13 (31.0)f | .01 |
| <Mediane | 88 (48.1) | 18 (38.3) | 29 (69.1)f | |
| Odds ratio (95% CI) | 1 [Reference] | 1.5 (0.8-2.9) | 0.4 (0.2-0.9) | |
| Adjusted odds ratio (95% CI)c | 1 [Reference] | 1.4 (0.7-2.8) | 0.5 (0.2-1.2) | |
Abbreviations: TCS, transgender congruence scale; TM, transmasculine.
Numbers may not add up to the total number of participants because, unless otherwise specified, we excluded categories with missing data totaling less than 10%.
Center for Epidemiologic Studies Depression Scale scores of 10 or greater indicated significant depressive symptoms.
Confounders included age, race, gender-affirming surgery status, education, and income. Missing variables were present and assigned a separate category for education and income, as they represented a unique group of individuals.
Beck Anxiety Inventory scores of 22 or greater indicated moderate to potentially concerning anxiety.
The TCS score lacks an established banding criteria for clinical interpretation, although prior analyses have dichotomized TCS by median score, with a score equal to or above the median indicating high body-gender congruence. Subscales of appearance congruence and gender identity acceptance were also reported.
Percentages do not add up to 100 because of rounding.
Discussion
Moderate-to-severe acne may be associated with clinically significant depression and anxiety symptoms among TM persons who received testosterone. Notably, TM persons in STRONG reported high levels of clinically significant depression and anxiety (47% and 21%, respectively). Even within the context of gender-affirming HT, moderate-to-severe acne negatively affected the mental health status of TM patients more commonly than the general population. One study of patients with acne across the UK showed that 18.5% developed depression over a 15-year period; our study showed that 71% and 50% of TM persons with current or past moderate-to-severe acne, respectively, reported clinically significant depression symptoms.5 Although isotretinoin may be rarely associated with mood changes, it has also been shown to improve quality of life and reduce depression symptoms in some studies.3,6 Isotretinoin has been used to treat moderate-to-severe acne effectively in transgender persons; its potential mental health benefits and risks must be considered in the context of the high baseline mental health symptoms among TM persons. Study limitations included a low response rate, the lack of validation of acne severity against objective measures, and limited generalizability to the broader, non–privately insured TM populations. Comprehensive multidisciplinary care, including screening and treatment for acne and mental health morbidity, is essential for TM patients who received testosterone with moderate-to-severe acne.
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