Abstract
Purpose:
The purpose of this study was to determine the existence and strength of association between chest dysphoria and mental health in transmasculine and nonbinary adolescents.
Methods:
This is a cross-sectional cohort study of transmasculine and nonbinary adolescents designated female at birth between 12 and 18 years old. None had undergone prior top surgery. Patients complete the Chest Dysphoria Measure and Youth Inventory-4 (YI-4) upon presentation to our institution. Outcomes were retrospectively reviewed. The primary outcome of interest was the association between chest dysphoria and anxiety and depression symptom severity, as measured by the YI-4.
Results:
One hundred fifty-six patients met inclusion criteria. Mean age was 15.3 years (standard deviation [SD] = 1.7). Most patients identified as transmasculine (n = 132); 18 identified as nonbinary and 6 as questioning. Mean (SD) YI-4 symptom severity scores were 10.67 (6.64) for anxiety and 11.99 (7.83) for depression. Mean (SD) Chest Dysphoria Measure composite score was 30.15 (9.95); range 2–49. Chest dysphoria was positively correlated with anxiety (r = .146; p = .002) and depression (r = .207; p < .001). In multivariate linear regression models, chest dysphoria showed a significant, positive association with anxiety and depression, after accounting for gender dysphoria, degree of appearance congruence, and social transition status.
Conclusions:
Chest dysphoria is associated with higher anxiety and depression in transmasculine and nonbinary adolescents designated female at birth. This association is independent of level of gender dysphoria, degree of appearance congruence, and social transition status. Treatment options aimed at alleviating chest dysphoria should be made accessible to adolescents and tailored to individual needs.
Keywords: Anxiety, Chest dysphoria, Depression, LGBT, Transgender, Transmasculine
Increasing numbers of high school students in the United States are identifying as transgender, nonbinary, or gender nonconforming, with recent estimates suggesting that up to 2.7% of adolescents affirm a gender identity different from their designated sex at birth [1]. Research suggests that transgender and nonbinary adolescents experience higher rates of depression and anxiety, suicidal ideation, and suicide attempts than their cisgender peers [2, 3–5]. Notably, transmasculine and nonbinary adolescents appear particularly at risk for suicidality, with 50.8% of transmasculine youth and 41.8% of nonbinary youth reporting past suicide attempts compared to 29.9% of transfeminine youth, 27.9% of gender questioning youth, 17.6% of cisgender girls, and 9.8% of cisgender boys [6]. Gender dysphoria, appearance congruence, and social transition status have all been linked to mental health functioning in transgender and non-binary youth [4,7–11].
A subset of adolescents designated female at birth who identify as transmasculine and/or nonbinary experience clinically significant distress due to chest development (i.e., growth of breast tissue) and associated impairment to daily living (e.g., dating/forming intimate partnerships; swimming or using locker rooms; fully participating in school and social life) [12,13]. As such, disruption of individual comfort, physical functioning, and interpersonal relationships due to chest discomfort are termed chest dysphoria [12,13]. Many transmasculine and/or nonbinary youth bind their chests with commercial binders, multiple sports bras, or elastic bandages to create the appearance of a flatter chest, alleviate chest dysphoria, or feel safe in public places [14]. While binding may mitigate the effects of chest dysphoria in social situations, however, it does not address internal distress and may impede physical function due to adverse effects such as musculoskeletal pain and poor posture [14,15].
It is not clear if and how chest dysphoria contributes to the clinical picture of mental health functioning in transmasculine and/or nonbinary adolescents designated female at birth. To address this knowledge gap, the primary aim of this study is to examine associations between chest dysphoria and self-reported anxiety and depression symptoms in a large cohort of transmasculine and nonbinary adolescents designated female at birth. We hypothesize that chest dysphoria will be positively and uniquely associated with anxiety and depression symptoms, even after accounting for gender dysphoria, appearance congruence, and social transition status. A secondary aim is to examine the construct of chest dysphoria separately among transmasculine and nonbinary youth designated female at birth, given literature suggesting that nonbinary youth have distinct mental health and clinical care needs compared to transgender youth with binary identities [16,17].
METHODS
Clinical database and study sample
All patients ages 12 years or older complete self-reported questionnaires upon initiation of care at the Ann and Robert H. Lurie Children’s Hospital of Chicago Gender and Sex Development Program (GSDP) [18]. Scores are entered into a clinical database in the Research Electronic Data Capture system (REDCap). This study used data from GSDP patients who (1) were designated female at birth; (2) were ages 12–18 years at initial visit; (3) identified as a gender other than female; and (4) completed the Chest Dysphoria Measure (CDM). The GSDP clinical database contains 1,076 records of patients seen between July 2013 and July 2019, of which 875 patients completed the questionnaires; distribution of the CDM started in April 2018, following the publication online of the CDM in March 2018. Of the 875 patients, 625 (71.4%) were designated female at birth and identified as a gender other than female; 591 (67.7%) met the additional age criteria between the ages of 12 and 18 years. Of these 591 patients, 156 (26.4%) received the CDM. No patients had undergone top surgery. This study was approved by the Lurie Children’s Institutional Review Board as an archival chart review study.
Variables and clinical measures
Demographics and clinical characteristics.
Designated sex at birth, gender identity at initial presentation to clinic, and date of birth were abstracted from medical charts. Patients, or parents of patients that are minors, complete a demographics measure at their first clinic visit; race was abstracted from this measure. History of pubertal suppression and testosterone therapy were ascertained from two items, which asked patients if they had taken any of the following actions: “Had puberty suppression therapy (“puberty blockers”)” and “Undergoing hormone replacement therapy.”
Chest dysphoria.
The CDM comprises 17 items measuring aspects of chest dysphoria related to physical functioning, intimate partnerships, being perceived as a member of a gender other than the individual’s expressed gender, and disruption of future plans (e.g., “I avoid exercise because of my chest”; “I feel like my life has not started because of my chest.”) [12]. Items are rated on a 4-point scale (0 = never, 3 = all the time) and summed with higher scores indicating more chest dysphoria. This measure has good internal consistency (Cronbach’s α = .89 for nonsurgical patients) [12].
Psychological functioning.
The Youth Inventory-4 (YI-4) is a self-report screening measure of Diagnostic and Statistical Manual of Mental Health Disorders IV criteria for emotional and behavioral disorders in adolescents aged 12–18 years [19,20]. Youth endorse the frequency of each symptom on a 4-point scale (0 = never, 3 = very often). Responses are summed to generate symptom severity scores for generalized anxiety disorder and major depressive disorder. Higher scores reflect more problem severity. Raw scores were not converted to standardized scores based on gender-referenced norms given the lack of professional consensus on the use of sex-normative data with transgender populations [21].
Gender dysphoria.
The Utrecht Gender Dysphoria Scale (UGDS) is a 12-item self-report measure of gender dysphoria severity [22]. Each item is rated on a 5-point Likert scale (1 = disagree completely, 5 = agree completely). Items include “I feel unhappy because I have to behave like a girl” and “Living as a girl is something positive for me.” Responses are summed, with higher score indicating greater gender dysphoria severity [22]. The UGDS has strong internal consistency (Cronbach’s α = .80) [23].
Appearance congruence.
The 9-item Appearance Congruence subscale of the Transgender Congruence Scale (TCS) measures the degree to which respondents feel their external appearance represents their gender identity (e.g., “I experience a sense of unity between my gender identity and my body”) [24]. Items are rated on a 5-point scale (1 = strongly disagree, 5 = strongly agree) and averaged with higher scores reflecting greater appearance congruence. The TCS has strong internal consistency (Cronbach’s α = .94) [24].
Social transition.
Social transition status was captured by a single yes/no question from the Gender Minority Stress and Resilience Measure: [25] “Do you currently live in your affirmed gender all or almost all of the time? Your affirmed gender is the one you see as accurate for yourself.”
Desire for top surgery.
The degree to which participants desire surgical transition was derived from a single question: “I think about having ‘top surgery.’” Response options are: Never, Less of the Week, Half of the Week, Most of the Week, Always, or I Already Had Surgery. Participants who responded Always or Most of the Week were categorized as “high” desire, and participants who responded Half of the Week, Less of the Week, or Never were categorized as “low” desire.
Analytic plan
Two multivariate linear regression models were conducted to examine associations between chest dysphoria and 1) anxiety symptom severity and 2) depression symptom severity. In each model, the predictors were CDM composite score, UGDS composite score, and Appearance Congruence subscale score. Both models were adjusted for social transition status as a potential confounder. Mean imputation techniques based on previously reported cutoffs for each scale were used to handle item-level missing data. For the YI-4 Symptom Severity Scores, Gadow and colleagues impute a mean of each individual’s nonmissing items if at least 75% of the items are complete (Kenneth D. Gadow, PhD, email communication, January 24, 2020). Mean imputation was performed for the CDM for all missing items because missing data were <5% for all items [12], for the UGDS when more than 85% of items were complete [22,26], and for the Appearance Congruence subscale when more than 86% of items were complete [24]. Finally, the two multivariate linear regression models were conducted with complete case analysis, in which any participant with a single or more missing item(s) on a measure was excluded to ensure that mean imputation did not change the direction or significance of associations [27]. Demographic and clinical characteristics were compared between subjects with (n = 38) and without any missing data (n = 118) (Supplemental Table 1).
Statistical analyses
Descriptive statistics for demographic variables (e.g., age, race, gender identity), clinical characteristics (e.g., history of pubertal suppression, testosterone therapy), and predictors and covariates were calculated for eligible youth who completed the CDM and those who did not. For group comparisons, independent samples t-tests were used for continuous variables and chi-squared tests for categorical variables. Mann-Whitney U tests were used when continuous data were not normally distributed, and Fisher’s exact tests were used for categorical variables when expected cell counts were small (<5). One-way analysis of variance assessed mean differences in chest dysphoria between groups by gender identity (e.g., transmasculine, nonbinary, and gender questioning) and age (e.g., 12–13.99 years, 14–15.99 years, and 16–18.99 years). Exploratory, post-hoc comparisons were done with Tukey’s multiple comparison test with correction for multiple comparisons. Independent samples t-test assessed mean differences in chest dysphoria between groups by desire for top surgery (e.g., high desire, low desire). All statistical analyses were performed using R (version 3.5.2) with significance threshold set at .05.
RESULTS
Demographic and clinical characteristics of study sample
One hundred fifty-six participants completed the CDM. Mean age was 15.3 years (standard deviation [SD] = 1.7). Most identified as transmasculine (n = 132); 18 identified as nonbinary and 6 as questioning. Racial/ethnic backgrounds were majority white (n = 107), followed by Hispanic/Latinx (n = 24), multi-racial (n = 8), Asian (n = 5), African-American (n = 3), and “other” (n = 2) (Table 1). One hundred twenty-seven patients had socially transitioned, two patients had undergone pubertal suppression, and one patient was actively using testosterone.
Table 1.
Demographic and clinical characteristics of study sample and GSDP clinical database designated female at birth sample
| Study sample (n = 156) | GSDP designated female at birth sample (n = 435) | p | Test | |
|---|---|---|---|---|
|
| ||||
| Age, mean (SD) | 15.34 (1.66) | 15.62 (1.62) | .060 | Independent Samples T |
| Race. n (%) | 0.8 | Fisher’s exact | ||
| White | 107 (68.6) | 288 (66.2) | ||
| African-American | 3 (1.9) | 16 (3.7) | ||
| Hispanic | 24 (15.4) | 58 (13.3) | ||
| Asian | 5 (3.2) | 21 (4.8) | ||
| Other | 2 (1.3) | 4 (.9) | ||
| Multi-Racial | 8 (5.1) | 30 (6.9) | ||
| Missing | 7 (4.5) | 18 (4.1) | ||
| Gender identity, n (%) | 0.7 | Fisher’s exact | ||
| Boy/man/masculine spectrum | 132 (84.6) | 376 (86.4) | ||
| Nonbinary | 18 (11.5) | 40 (9.2) | ||
| Questioning | 6 (3.8) | 16 (3.7) | ||
| Unknown | 0 (.0) | 3 (.7) | ||
| Utrecht Gender Dysphoria Score, median (IQR) | 57.00 (53.00, 59.00) | 55.00 (52.00, 59.00) | .014* | Mann-Whitney U |
| Appearance Congruence Score, mean (SD) | 2.12 (.74) | 2.23 (.82) | .16 | Independent Samples T |
| YI-4 Depression Score, mean (SD) | 11.99 (7.83) | 14.19 (6.32) | .001* | Independent Samples T |
| YI-4 Anxiety Score, mean (SD) | 10.67 (6.64) | 12.93 (5.60) | <.001* | Independent Samples T |
| GMSR Transitioning Item, n (%) | .011* | Fisher’s exact | ||
| Yes | 127 (81.4) | 245 (56.3) | ||
| No | 29 (18.6) | 101 (23.2) | ||
| Missing | 0 (0) | 89 (20.5) | ||
| Have taken puberty suppression hormones, n (%) | 1.0 | Fisher’s exact | ||
| Yes | 2 (1.3) | 5 (1.1) | ||
| No | 151 (96.8) | 265 (60.9) | ||
| Missing | 3 (1.9) | 165 (37.9) | ||
| Undergoing testosterone therapy, n (%) | 0.3 | Fisher’s exact | ||
| Yes | 1 (.6) | 7 (1.6) | ||
| No | 150 (96.2) | 265 (60.9) | ||
| Missing | 5 (3.2) | 163 (37.5) | ||
IQR = interquartile range; GMSR = Gender Minority Stress and Resilience; GSDP = Gender and Sex Development Program.
Statistical significant.
Median (interquartile range) gender dysphoria composite score was 57 (53–59); range 40–60. Mean (SD) appearance congruence composite score was 2.12 (.74); range 1–4. The mean (SD) symptom severity scores were 10.67 (6.64) for anxiety and 11.99 (7.83) for depression (Table 1). There were significant differences between the study sample (n = 156) and GSDP patients who did not complete the CDM (n = 435). The study sample had higher levels of gender dysphoria (median [interquartile range] 57 [53–59] vs. 55 [52–59]; p = .014), lower anxiety symptom severity (mean [SD] 10.67 [6.64] vs. 12.93 [5.6]; p < .001), and lower depression symptom severity (mean [SD] 11.99 [7.83] vs. 14.19 [6.32]; p = .001) than the GSDP patients.
Chest dysphoria in study sample
The mean (SD) CDM composite score was 30.15 (9.95); range 2–49. On an item level, over two-thirds of respondents reported worrying that people were looking at their chest (85%), having to buy/wear certain clothes (85%), avoiding swimming in public (74%) places, and avoiding locker rooms (72%) because of their chests (Table 2). A majority of the sample felt that forming intimate partnerships (54%), engaging in intimate activity (59%), and taking a shower or bath (67%) were more difficult because of their chest. Impact of the chest on overall life engagement was mixed: 53% reported participating in life less than others, 46% reported struggling to make future plans, and 58% reported feeling like life had not started because of their chest.
Table 2.
Item-level responses to chest dysphoria measure in study sample
| Chest dysphoria measure: (item number) question | Participants endorsing item in study Samplea,b (n = 156) n (%) |
|---|---|
|
| |
| (1) I like looking at my chest in the mirror | 3 (1.9) |
| (2) Taking a shower/bath is difficult because I have to see my chest | 104 (66.7) |
| (3) I avoid going to the beach and/or swimming in public places because of my chest | 114 (73.5)b |
| (4) I get gendered as female because of my chest | 80 (51.3) |
| (5) Dating/forming intimate partnerships is more difficult because of my chest | 82 (54.3)b |
| (6) Physical intimacy/sexual activity is difficult because of my chest | 87 (59.2)b |
| (7) I have struggled to make future plans because of my chest | 70 (45.8)b |
| (8) I avoid exercise because of my chest | 78 (50) |
| (9) I avoid shopping/buying clothing because of my chest | 65 (41.7) |
| (10) I avoid seeking medical care because of my chest | 30 (19.5)b |
| (11) I feel like my life has not started because of my chest | 89 (58.2)b |
| (12) I avoid swimming in private places because of my chest | 91 (59.5)b |
| (13) I have to buy/wear certain clothes because of my chest | 132 (84.6) |
| (14) I sleep with a binder at night | 23 (14.9)b |
| (15) I avoid using locker rooms because of my chest | 112 (72.3)b |
| (16) I worry that people are looking at my chest | 131 (83.9) |
| (17) I participate in life less than others because of my chest | 82 (52.6) |
Frequencies and corresponding percentages represent combined responses of “frequently” and “all the time.” Answer choices for each item are “never,” “sometimes,” “frequently,” and “all the time.”
Items where n < 156 due to missing single-item responses: (3) n = 155; (5) n = 151; (6) n = 147; (7) n = 153; (10) n = 154; (11) n = 153; (12) n = 153, (14) n = 154; (15) n = 155.
Association of chest dysphoria with anxiety and depression symptoms
Chest dysphoria was positively correlated with anxiety (r = .146; p = .002) and depression (r = .207; p < .001). Chest dysphoria was also positively correlated with gender dysphoria (r = .380; p < .001) and negatively correlated with appearance congruence (r = −.198; p = .014). In the multivariate linear regression models, chest dysphoria showed a significant, positive association with anxiety and depression. With each unit increase in chest dysphoria, mean anxiety symptom severity increased by .16 (β [SE], .162 [.05]; p = .002) and depression symptom severity increased by .23 (β [SE], .230 [.06]; p < .001). Unexpectedly, gender dysphoria was negatively associated with anxiety symptom severity (β [SE], −.232 [.105]; p = .029). The direction and significance of these associations held when univariate correlations and multivariate linear regressions were performed with the complete case sample (n = 118) (Table 3).
Table 3.
Univariate and multivariable associations of chest dysphoria, gender dysphoria, appearance congruence, and anxiety and depression symptoms
| Mean imputation, univariate [r (p-value)] | ||||
|---|---|---|---|---|
|
| ||||
| Anxiety (n = 133) | Depression (n = 132) | Gender dysphoria | Appearance congruence | |
|
| ||||
| Chest dysphoria | .146; p = .002* | .207; p < .001* | .380; p < .001* | −.198; p = .014* |
| Gender dysphoria | −.134; p = .19 | .003; p = 0.9 | .011; p = 0.9 | |
| Appearance congruence | −1.792; p = .006* | −1.525; p = .055 | ||
|
| ||||
| Mean imputation, multivariable [β (SE); p-value] | ||||
| Anxiety (n = 133) | Depression (n ¼ 132) | |||
|
| ||||
| Chest dysphoria | .162 (.050); p = .002* | .230 (.063); p < .001* | ||
| Gender dysphoria | −.232 (.105); p = .029* | −.148 (.129); p = 0.3 | ||
| Appearance congruence | −1.125 (.667); p = .09 | −.653 (.806); p = 0.4 | ||
| GMSR transition item, yes | −.965 (1.320); p = 0.5 | −.800 (1.643); p = 0.6 | ||
|
| ||||
| Complete case, univariate [r; p-value] (n = 118) | ||||
| Anxiety | Depression | Gender dysphoria | Appearance congruence | |
|
| ||||
| Chest dysphoria | .154; p = .003* | .207; p = .001* | .379; p < .001* | −.259; p = .005* |
| Gender dysphoria | −.164; p = .19 | .041; p = 0.8 | .076; p = 0.4 | |
| Appearance congruence | −1.948; p = .005* | −1.738; p = .042* | ||
|
| ||||
| Complete case, multivariable [β (SE); p-value] (n = 118) | ||||
| Anxiety | Depression | |||
|
| ||||
| Chest dysphoria | .181 (.056); p = .002* | .210 (.070); p = .003* | ||
| Gender dysphoria | −.293 (.131); p = .027* | −.110 (.163); p = 0.5 | ||
| Appearance congruence | −1.111 (.704); p = .12 | −.838 (.878); p = 0.3 | ||
| GMSR transition item, yes | −.984 (1.425); p = 0.5 | −1.449 (1.776); p = 0.4 | ||
GMSR = Gender Minority Stress and Resilience.
Statistical significant.
Subgroup analyses of chest dysphoria
Chest dysphoria composite scores did not differ significantly between transmasculine, nonbinary, and questioning adolescents (Table 4). Chest dysphoria was significantly greater in 14–16 (33.82 [8.8]) and 16 to 18 (30.39 [9.53]) year old participants than in 12- to 14-year-old participants (23.97 [9.9]) (p < .001 and p = .005, respectively). Finally, individuals reporting “high” desire for top surgery experienced significantly greater chest dysphoria (mean [SD] 31.72[9.20]; n = 128) than those with a “low” desire for top surgery (mean [SD] 22.19[10.07]; n = 26; p < .001).
Table 4.
Chest dysphoria composite score mean in entire sample and by gender identity, desire for top surgery, and age
| Chest dysphoria Composite score, mean (SD) | By gender identity | By desire for top surgery | By age | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
||||||||
| Total sample N = 156 | Trans-man n = 132 | Nonbinary n = 18 | Questioning n = 6 | p | Low n = 26 | High n = 128 | p | 12–13.99 n = 36 | 14–15.99 n = 66 | 16–18.99 n = 54 | p |
|
| |||||||||||
| 30.15 (9.95) | 30.85 (9.87) | 27.17 (9.47) | 23.67 (10.76) | .09 | 22.19 (10.07) | 31.72 (9.2) | <.001 | 23.97 (9.9) | 33.82 (8.81) | 30.39 (9.53) | <.001 |
DISCUSSION
This study is only the second to quantitatively examine chest dysphoria as a distinct construct [12]. Limited research examines the prevalence of chest dysphoria and its psychological impact on transmasculine and/or nonbinary youth designated female at birth, however have failed to objectively measure chest dysphoria [13,28]. In this large sample of adolescents presenting for care at a Midwestern, urban pediatric gender clinic, a majority experienced difficulty in intimate partnerships, aspects of physical functioning, and negative feelings related to being misgendered due to their chest. Overall chest dysphoria level was significantly higher in 14- to 16- and 16- to 18-year-old adolescents, as compared to 12- to 14-year-old youth. These findings highlight the varied, predominant disruptions in functioning, as well as fluctuations in severity over time, that transmasculine and/or nonbinary adolescents designated female at birth may experience from discomfort with their chest. Increasing Tanner stage and development of breast tissue over time may contribute to increased chest dysphoria in older adolescence. Age may increase the number of negative encounters and experiences related to the chest. There was no association with gender identity, although this was likely limited by the low representation of nonbinary and questioning individuals within our sample.
Greater levels of chest dysphoria were associated with greater gender dysphoria, lower appearance congruence, and higher anxiety and depression symptoms. This study is the first to examine associations between the CDM, developed in the past two years, with well-established and clinically relevant constructs [12]. Notably, greater levels of chest dysphoria indicated higher anxiety and depression, independent of gender dysphoria, degree of appearance congruence, and social transition status. Thus, we believe that chest dysphoria should be viewed as a clinically important and qualitatively distinct construct from gender dysphoria that warrants consideration.
Transmasculine and/or nonbinary individuals designated female at birth adolescents are at high risk for negative sequelae from mental health morbidity and maladaptive coping mechanisms, including substance use and abuse, and suicide attempts [5]. Although this study does not establish causality, the association between chest dysphoria and anxiety and depression symptoms lends preliminary support to the notion that treating chest dysphoria may improve anxiety and depression symptoms in transmasculine and/or nonbinary adolescents designated female at birth. Indeed, a primary aim of gender-affirming medical and surgical intervention in youth is to improve mental health functioning [29,30]. Possible interventions to target chest anatomy in transmasculine and/or nonbinary adolescents include pubertal suppression to prevent breast development, safe chest binding practices, and mastectomy and chest masculinization (i.e., top surgery) [31]. Mastectomy and chest masculinization (i.e., top surgery) constitute surgical interventions that are increasingly performed in the United States to treat chest dysphoria [32,33]. In adults, surgery has been associated with postoperative improvement in patient-reported body image, sexual satisfaction, self-esteem, and quality of life [34–38]. Among adolescents and young adults aged 13–25 years, a recent retrospective cohort study of nonsurgical versus postsurgical transmasculine youth documented significantly lower chest dysphoria in postsurgical patients [12]. Our data show a cross-sectional link between adolescents’ desire for top surgery and level of chest dysphoria, highlighting that inner thoughts about surgical intervention relate to the degree of impairment adolescents experience from female chest anatomy.
Inconsistent with previous research, gender dysphoria was negatively associated with anxiety symptoms in this study sample. This finding may be within study error as it does not align with clinical experience or previous literature. Notably, the TCS total scale, which measures the related construct of gender congruence, did not show this spurious relationship. Our study’s finding highlights the continued need to understand the relationships between gender dysphoria, mental health functioning, and gender identity in transgender adolescents.
Limitations
As with most clinic-based studies of transgender people, our sample includes adolescents who are predominantly white [4,12,39]. In order for minors to access care at the GSDP, some degree of parental support is required. Prevalence of anxiety and depression symptoms may be underrepresented compared to transgender adolescents who do not possess the resources or parental support required to access gender-affirming care [40]. Second, this study examined the association between chest dysphoria and mental health functioning at a single time point. Longitudinal research is required to study the effects of time in care and various treatments on the relationship between chest dysphoria, anxiety, and depression. Despite these limitations, this study represents only the second large-scale report of chest dysphoria, is specific to a population of adolescents at high-risk for anxiety and depression, and establishes a novel, clinically relevant association between chest dysphoria and mental health functioning. Because self-reported measures were completed at initiation of care, the study sample was largely naïve to puberty suppression and gender-affirming hormones, which would alter chest development.
Other characteristics which we could not account for include chest size, body mass index, fat distribution, and chest binding practices. We acknowledge that it is possible that patients with greater chest tissue will report higher levels of chest dysphoria. However, in our clinical experience with transmasculine and nonbinary individuals with gender dysphoria and cis-males with gynecomastia, it is the mere presence of the breasts rather than the size that appears to cause distress. Body fat distribution and body mass index may confound the relationship between anxiety/depression severity scores and chest dysphoria. Chest binding practices could not be controlled for as an independent variable, but is included as an item in the CDM. We acknowledge the effects that gender-affirming hormone therapy may have on mental health outcomes and functioning. One patient in the cohort was receiving testosterone therapy. Excluding the patient did not alter the results of the study, and because it is unclear to what degree gender-affirming therapy contributed to this patient’s chest dysphoria, the patient remains in the final analysis. Finally, the present study is limited by lower representation of nonbinary participants; future studies will hopefully contain larger cohorts of nonbinary patients, who remain understudied.
Although there were significant differences between our study sample and the larger GSDP sample of youth designated female at birth in mean gender dysphoria, anxiety, and depression scores, there were no changes in clinic enrollment or care procedures that may have caused a biased shift between the two groups. The CDM as administered to all patients after it was introduced in early 2018. Passage of time and associated social, political, and legal changes in transgender health in the United States may account for the differences, though these effects may be impossible to quantify.
CONCLUSIONS
Understanding relationships between various aspects of transgender experiences and mental health functioning is critical to establishing clinical guidelines that promote adequate access to gender-affirming psychological, medical, and surgical care for transgender adolescents. This study shows that higher levels of impairment and distress from breast anatomy—chest dysphoria—are associated with higher anxiety and depression in transmasculine and/or nonbinary adolescents at the time of presentation for gender-affirming care. This novel association is independent of level of gender dysphoria, degree of appearance congruence, and social transition status. Thus, chest dysphoria is a clinically relevant, independent construct that should be further described in various transmasculine and/or nonbinary populations. Future research should explore longitudinal changes in chest dysphoria and associated mental health functioning, as well as explore effectiveness of treatment modalities. Treatment options aimed at alleviating chest dysphoria should be made accessible to adolescents and tailored to individual needs.
Supplementary Material
IMPLICATIONS AND CONTRIBUTION.
Chest dysphoria was associated with anxiety and depression symptoms in transmasculine and nonbinary adolescents designated female at birth. These associations were independent of gender dysphoria, appearance congruence, and social transition status. Chest dysphoria should be addressed as part of the treatment plan for transmasculine and nonbinary adolescents seeking gender-affirming care.
Funding Sources
The present study was funded by the Plastic Surgery Foundation-American Association of Pediatric Plastic Surgeons (PSF-AAPPS) Combined Pilot Research Grant. The present study was also funded in part by the National Institutes of Health’s National Center for Advancing Translational Sciences, Grant Number UL1TR001422, awarded to the Northwestern University Clinical and Translational Sciences Institute.
Footnotes
Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jadohealth.2021.02.024.
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