Abstract
This secondary analysis uses data from the 2015 US Transgender Survey to assess the association between gender-affirming hair removal procedures and mental health among transgender individuals.
Gender-affirming medical care is essential for addressing the mental health burdens of transgender and gender-diverse (TGD) populations.1 Gender-affirming hair removal (GAHR) procedures, including electrolysis and laser hair removal, are desired by nearly 90% of TGD people.2 However, such services are covered by only 4.6% of insurance plans,3,4 possibly owing in part to limited evidence of their menatal health benefits. In this study, we investigated the association between GAHR and mental health outcomes.
Methods
We conducted secondary analysis of the 2015 US Transgender Survey (USTS), a cross-sectional, nonprobability survey of 27 715 US TGD adults disseminated by community outreach from August 19, 2015, to September 21, 2015.2 The protocol was reviewed by the Fenway Institute institutional review board and was deemed to not constitute human subjects research.
Respondents assigned male sex at birth were asked, “have you had or do you want any of the health care listed below for gender transition?” for various gender-affirming procedures, including “hair removal/electrolysis.” The exposure group included respondents who reported undergoing GAHR. The control group included respondents who reported a desire for but had not had GAHR.
Five binary mental health outcomes were examined: past-month severe psychological distress (K6 score ≥13),5 past-month binge alcohol use (≥5 drinks on 1 occasion), past-year tobacco smoking, past-year suicidal ideation, and past-year suicide attempt.
All analyses were conducted using Stata statistical software (version 16.1; StataCorp, LLC). Multivariable logistic regression models were generated with covariates including sociodemographics and exposure to other gender-affirming care (Table 1). Models were survey weighted to correct sampling biases related to age and race or ethnicity. Variable interactions were not examined. Adjusted odds ratios (aORs), 95% confidence intervals (95% CIs), and 2-sided P values are reported.
Table 1. Sample Sociodemographics.
| Characteristic | No. (%) | Difference, % (95% CI)c | |
|---|---|---|---|
| Control (n = 5652)a | Exposure (n = 4927)b | ||
| Age, y | |||
| 18-44 | 4273 (75.6) | 2777 (56.4) | 19.2 (17.5 to 21.0) |
| 45-64 | 1154 (20.4) | 1756 (35.6) | −15.2 (−16.9 to −13.5) |
| ≥65 | 225 (4.0) | 394 (8.0) | −4.0 (−4.9 to −3.1) |
| Education | |||
| Less than high school | 192 (3.4) | 65 (1.3) | 2.1 (1.5 to 2.6) |
| High school graduate up to associate’s degree | 3831 (67.8) | 2172 (44.1) | 23.7 (21.9 to 25.5) |
| Bachelor's degree or higher | 1629 (28.8) | 2690 (54.6) | −25.8 (−27.6 to −24.0) |
| Employment | |||
| Employed | 3451 (61.1) | 3576 (72.6) | −11.5 (−13.3 to −9.7) |
| Unemployed | 868 (15.4) | 377 (7.7) | 7.7 (6.5 to 8.9) |
| Out of labor force | 1296 (22.9) | 958 (19.4) | 3.5 (1.9 to 5.0) |
| Family rejection | |||
| Yes | 2636 (46.6) | 3211 (65.1) | −18.5 (−20.4 to −16.7) |
| No | 2401 (42.4) | 1589 (32.2) | 10.2 (8.4 to 12.1) |
| Gender identity | |||
| Crossdresser | 431 (7.6) | 107 (2.2) | 5.5 (4.7 to 6.3) |
| Trans woman | 4211 (74.5) | 4551 (92.4) | −17.9 (−19.2 to −16.5) |
| Trans man | 10 (0.2) | 6 (0.1) | 0.1 (−0.1 to 0.2) |
| Nonbinary | 1000 (17.7) | 263 (5.3) | 12.4 (11.2 to 13.5) |
| Health insurance | |||
| Uninsured | 950 (16.8) | 494 (10.0) | 6.8 (5.5 to 8.1) |
| Insured | 4690 (83.0) | 4428 (89.9) | −6.9 (−8.1 to −5.6) |
| Household income, $ | |||
| <25 000 | 2093 (37.0) | 1016 (20.6) | 16.4 (14.7 to 18.1) |
| 25 000-99 999 | 2326 (41.2) | 2377 (48.2) | −7.1 (−9.0 to −5.2) |
| ≥100 000 | 768 (13.6) | 1264 (25.7) | −12.1 (−13.6 to −10.6) |
| Race | |||
| White | 4714 (83.4) | 4269 (86.7) | −3.2 (−4.6 to −1.9) |
| Alaska Native/American Indian | 84 (1.5) | 49 (1.0) | 0.5 (0.1 to 0.9) |
| Asian/Native Hawaiian/Pacific Islander | 147 (2.6) | 122 (2.5) | 0.1 (−0.5 to 0.7) |
| Black/African American | 175 (3.1) | 92 (1.9) | 1.2 (0.6 to 1.8) |
| Latinx/Hispanic | 264 (4.7) | 218 (4.4) | 0.2 (−0.5 to 1.0) |
| Other/biracial/multiracial | 268 (4.7) | 177 (3.6) | 1.1 (0.4 to 1.9) |
| Sexual orientation | |||
| Asexual | 399 (7.1) | 337 (6.8) | 0.2 (−0.8 to 1.2) |
| Lesbian, gay, bisexual | 4123 (72.9) | 3533 (71.7) | 1.2 (−0.5 to 3.0) |
| Heterosexual | 766 (13.6) | 768 (15.6) | −2.0 (−3.4 to −0.7) |
| History of other gender-affirming medical care | |||
| Counseling/therapy | 3135 (55.5) | 4295 (87.2) | −31.7 (−33.3 to −30.1) |
| Pubertal suppression | 109 (1.9) | 137 (2.7) | −0.9 (−1.4 to −0.3) |
| Hormone therapy | 2423 (42.9) | 4348 (88.2) | −45.4 (−47.0 to −43.8) |
| Surgery | 237 (4.2) | 1855 (37.6) | −33.5 (−34.9 to −32.0) |
The control group consists of respondents who desired gender-affirming hair removal but had not received it.
The exposure group consists of respondents who endorsed history of gender-affirming hair removal.
Column percentages may not add up to 100% because missing data are not displayed.
To determine whether baseline mental health status could confound observed associations, we generated 4 multivariable logistic regression models adjusted for all covariates in Table 1, regressing exposure to GAHR against lifetime suicidal ideation, suicide attempts, alcohol use, and smoking.
Bonferroni correction was applied to adjust for 9 tests, with P < .005 considered statistically significant. Because the maximum percentage of respondents with missing data was low (11% across all variables), complete case analysis was performed.
Results
Of 27 715 USTS respondents, 11 857 (42.8%) reported being assigned male sex at birth. Of these respondents, 4927 (41.6%) had undergone hair removal, whereas 5652 (47.7%) desired hair removal but had not yet received it (Table 1).
After adjustment for sociodemographic factors and other gender-affirming care, GAHR was associated with lower odds of past-month severe psychological distress (aOR, 0.62; 95% CI, 0.53-0.73; P < .001); past-year smoking (aOR, 0.76; 95% CI, 0.65-0.89; P < .001); and past-year suicidal ideation (aOR, 0.72; 95% CI, 0.62-0.84; P < .001) (Table 2). There was no significant association between GAHR and past-month binge alcohol use or past-year suicide attempts. Exposure to GAHR was not significantly associated with lifetime suicidal ideation, suicide attempts, alcohol use, or smoking.
Table 2. Mental Health Outcomes Based on History of Gender-Affirming Hair Removal.
| Variable | Respondents endorsing, No. (%) | aOR (95% CI)c | P value | |
|---|---|---|---|---|
| Control (n = 5652)a | Exposure (n = 4927)b | |||
| Severe psychological distress (past month) | 2301 (40.7) | 1066 (21.6) | 0.62 (0.53 to 0.73) | <.001 |
| Substance use | ||||
| Binge alcohol use (past month) | 1490 (26.3) | 1104 (22.4) | 0.91 (0.78 to 1.07) | .26 |
| Smoking (past year) | 1814 (32.1) | 1125 (22.9) | 0.76 (0.65 to 0.89) | <.001 |
| Suicidality (past year) | ||||
| Ideation | 2910 (51.5) | 1957 (39.7) | 0.72 (0.62 to 0.84) | <.001 |
| Attempt | 523 (9.3) | 261 (5.3) | 0.74 (0.56 to 0.98) | .03 |
Abbreviation: aOR, adjusted odds ratio.
The control group consists of respondents who desired gender-affirming hair removal but had not received it.
The exposure group consists of respondents who endorsed history of gender-affirming hair removal.
Adjusted odds ratios compare the odds of experiencing each mental health outcome in the exposure group compared with the control group. All models were adjusted for: age, education, employment, family rejection, gender identity, health insurance, household income, race, sex assigned at birth, and sexual orientation. Additional covariates included exposure to gender-affirming counseling, pubertal suppression, hormone therapy, and surgery (including breast augmentation, orchiectomy, tracheal shave, facial feminization surgery, voice surgery).
Discussion
This is the first large-scale controlled study demonstrating associations between GAHR and improved mental health outcomes, including decreased psychological distress, past-year smoking, and past-year suicidal ideation. These findings reinforce the only existing empirical investigation, to our knowledge, on this subject—a small-scale study demonstrating that GAHR is associated with improved mental health and quality of life.6 Reverse causality is possible, as TGD people with better baseline mental health may be more likely to access GAHR. However, baseline mental health was not associated with exposure to GAHR in our models. Further studies are needed to clarify this relationship.
This study’s strengths include its large, national sample size and comprehensive adjustment for confounders. Limitations include its cross-sectional design, convenience sample, potential response bias, and lack of validity and reliability data for USTS questions. Nonetheless, this study contributes novel evidence of the potential mental health benefits of GAHR for TGD people.
References
- 1.Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412-436. doi: 10.1016/S0140-6736(16)00684-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Reports USTS. 2015. U.S. Trans Survey. Accessed March 16, 2021. https://www.ustranssurvey.org/reports
- 3.Peloza K, Kahn B, Stoff BKM, Yeung H. Insurance coverage for hair removal procedures in the treatment of gender dysphoria. Dermatol Surg. 2021;47(2):306-308. doi: 10.1097/DSS.0000000000002234 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Thoreson N, Marks DH, Peebles JK, King DS, Dommasch E. Health insurance coverage of permanent hair removal in transgender and gender-minority patients. JAMA Dermatol. 2020;156(5):561-565. doi: 10.1001/jamadermatol.2020.0480 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60(2):184-189. doi: 10.1001/archpsyc.60.2.184 [DOI] [PubMed] [Google Scholar]
- 6.Bradford NJ, Rider GN, Spencer KG. Hair removal and psychological well-being in transfeminine adults: associations with gender dysphoria and gender euphoria. J Dermatol Treat. Published online November 22, 2019. doi: 10.1080/09546634.2019.1687823 [DOI] [PubMed] [Google Scholar]