Psychosocial Resources and Quality of Life in Transgender Women following Gender-Affirming Surgery

ORIGINAL RESEARCH & REVIEWS

TRANSGENDER HEALTH

Psychosocial Resources and Quality of Life in Transgender Women following Gender-Affirming Surgery Anja Breidenstein, PhD,1 Jochen Hess, MD,2 Boris Hadaschik, MD,2 Martin Teufel, MD,1 and Sefik Tagay, PhD1 ABSTRACT

Introduction: Psychosocial resources like social support or intrapersonal coping skills play an important role in resilience and quality of life (QOL), yet research systematically investigating the availability of different resources and QOL in transgender (trans) women is missing. Aim: The present study aimed to systematically investigate the existence of different psychosocial resources and QOL in trans women following gender-affirming surgery (GAS). Methods: Using a cross-sectional design, 557 trans women who had received GAS at the local urological department were invited to study participation. Criteria for study inclusion were 18 years and older, diagnosis of transsexualism according to the International Classification of Disease, completion of all sessions of GAS, and given written informed consent to study participation. Main Outcome Measures: Psychosocial resources were assessed using the Essen Resource Inventory (ERI), the Sense of Coherence Scale, and the Social Support Scale. QOL was assessed with the Short Form Health Survey. Data from trans women were compared to normative data of healthy non-trans women as reported in the respective test manuals. Results: In total, 158 trans women responded and participated in this study. They had received GAS 4 months to 21 years ago. The total sample was divided into 3 subgroups depending on the time interval since the participants’ last GAS procedure (group 1: GAS 0.3
3 years ago (n ¼ 48); group 2: GAS 3.1
10 years ago (n ¼ 62); and group 3: GAS 10.1
21 years ago (n ¼ 41)). Trans women retrospectively indicated their available resources 3 years ago (ERI 3-years) and in the last 4 weeks (ERI 4-weeks). Trans women who had received GAS within the last 3 years (group 1) showed an increase in resources when comparing ERI 3-year scores (presurgery) with ERI 4-week scores (postsurgery). No differences emerged for group 2 and group 3. Compared to normative data from non-trans women, trans women scored significantly lower on the ERI but not in measures of Social Support Scale or Sense of Coherence Scale. Compared to nontrans women, mental QOL was significantly impaired in trans women, whereas no differences in physical QOL emerged. Clinical Implications: As this study hints towards reduced psychosocial resources in trans women, the offering of specialized counseling can have high beneficial potential to support the development of resources, thereby enhancing QOL. Strength & Limitations: Data of a large sample of trans women is provided who were investigated up to 21 years after GAS. The study is limited by its cross-sectional design and the response rate of 42%. Conclusion: This study indicates that psychosocial resources improve around the time of GAS and seem to be improved and sustained in later years following GAS. Still, compared to non-trans women, trans women have a lower availability of resources and a lower mental QOL. Breidenstein A, Hess J, Hadaschik B, et al. Psychosocial Resources and Quality of Life in Transgender Women following Gender-Affirming Surgery. J Sex Med 2019;16:1672e1680. Copyright
2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Key Words: Gender Dysphoria; Gender Identity Disorder; Transgender; Transsexualism; Gender-Affirming Surgery; Psychosocial Resources; Social Support Received March 10, 2019. Accepted August 5, 2019. 1

Department of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, Essen, Germany;

2

Department of Urology, University Hospital Essen, Essen, Germany

Copyright ª 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2019.08.007

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INTRODUCTION In people with gender dysphoria, the subjectively perceived gender identity does not match the biological sex assigned at birth causing discomfort or distress. Many of them wish to adapt their physical sex characteristics to the preferred gender and seek J Sex Med 2019;16:1672e1680

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medical treatment such as hormone therapy or gender-affirming surgery (GAS).1 People diagnosed with gender dysphoria are often referred to as transgender (trans) women (assigned men with female gender identity) and trans men (assigned women with male gender identity). However, an increasing body of knowledge indicates that gender is more multifaceted than this distinction.2 The process of transitioning (the process of changing the social gender presentation and the biological sex (eg, with the help of hormonal and surgical treatments)3 may be accompanied by different psychosocial strains that can influence a person’s well-being. Quality of life (QOL) constitutes an important indicator for a person’s subjective well-being. It is a multidimensional construct comprising at least a physical, mental, and social dimension.4 Studies investigating QOL of trans women have revealed mixed results. Although some studies have reported same levels of QOL in trans women when compared to the general population,5
7 others have revealed lower QOL in trans women.8,9 This mixed result pattern probably results from the different study designs and the different characteristics of the investigated samples. So far, research evaluating the long-term changes in QOL in trans women is scarce. A longitudinal study investigating adolescent trans women and men between the start of puberty suppression and the completion of gender-affirming procedures has revealed that GAS and hormone therapy were associated with a steady improvement of gender dysphoria and subjective well-being. Especially trans women showed improvements in psychological functioning and body image satisfaction after treatment.10 Lindqvist et al9 have assessed QOL in trans women before as well as 1, 3, and 5 years after GAS. The authors could show that QOL was significantly higher 1 year after GAS when compared to baseline assessment and remained stable in the following years. Furthermore, several studies have revealed that hormone intake and GAS were associated with an improved QOL in trans men and women.7,9
12 The availability of protective factors and individual resources that can strengthen a person’s resilience throughout the transition is of special interest. Tagay et al13 differentiated among 3 different dimensions of psychosocial resources: personal, social, and structural resources. Personal resources are described as character traits or abilities that originate in the individual’s personality (eg, perceived self-efficacy, openness to new experiences, or emotion regulation strategies). Social resources comprise the subjectively perceived social support or the availability of positive social relationships. Studies on the effects of social support in trans women emphasize its stress-buffering effects14 and its importance for QOL.15,16 The dimension of structural resources describes a person’s supporting environment, residential situation, or financial security. Studies that point toward the important influence of socioeconomic and employment status on QOL in trans men and women underline the importance of structural resources.6,17 Furthermore, the Sense of Coherence (SOC)18

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scale represents another important personal resource. The SOC scale describes a person’s ability to flexibly react to life changes and to integrate (adverse) experiences into their own biography. A plethora of research indicates that a high SOC is associated with good mental and physical health underlining its high protective potential (for review see ref. 19). However, research systematically investigating the availability of different psychosocial resources in trans women is missing. Especially, the investigation of personal resources has so far not been in the focus of research. Furthermore, little is known about QOL and the availability of psychosocial resources in trans women up to 21 years after GAS. Therefore, the objective of the present study was to investigate for the first time QOL and the existence of personal, social, and structural resources in trans women following GAS. Additionally, differences between recently transitioned individuals and individuals who have completed their transition up to 21 years ago were examined to investigate time-dependent differences of the parameters of interest. As exclusively male-to-female GAS is offered at the local urological department providing a large sample of trans women, the present study focuses on trans women.

MATERIALS AND METHODS Study Design and Sample The research question was addressed using a cross-sectional design. The study protocol was approved by the local ethics committee (number of ethics committee approval: 15-6544-BO). All participants provided written informed consent to study participation. The internal database of the clinic was searched to identify all trans women who had received GAS at the Department of Urology at the University Clinic in Essen between January 1, 1995, and October 31, 2015. Figure 1 presents a flow diagram of participant inclusion. Data sampling took place between February 1, 2016, and August 31, 2016. Participants were invited to study participation via mail and received study information and a set of questionnaires. All participants were aged 18 years or older, had a diagnosis of transsexualism (male-to-female) according to the International Classification of Disease version 1020 and had sufficient knowledge of the German language. All participants had completed 2 surgical procedures of GAS. Within the first session, patients underwent penile inversion vaginoplasty, including bilateral orchiectomy, penectomy, and formation of a sensible glans-derived clitoroplasty. The second step procedure was performed after at least 6
8 weeks and comprised a surgical correction of the introitus vagina and, if necessary, minor aesthetical and functional corrections (eg, meatoplasty and labioplasty). All participants had received medical appraisal by at least 2 external mental health professionals prior to surgery to confirm the diagnosis of transsexualism. Data from trans women in the current sample were compared to normative data of healthy, agematched, non-trans women, as reported in the manual of the respective test instruments.

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Breidenstein et al Trans women who have received gender-affirming surgery at the Department of Urology at the University hospital in Essen between January 1995 and October 2015 N = 610 Insufficient data available in clinic n = 23 Ineligible n = 30 Trans women contacted for study parcipaon n = 557

Post returned as undeliverable n = 168 Deceased n = 14

Trans women who received study invitaon n = 375 No response n = 210 Not interested in parcipaon n=7 Trans women included in study N = 158

Figure 1. Flow-chart of participant inclusion into the study sample. Ineligible persons did not meet inclusion criteria (eg, had not yet completed all sessions of gender-affirming surgery). Of the 375 persons who received the study invitation, 158 participated. This results in a response rate of 42%.

Materials The following sociodemographic information was collected: age, date of last GAS, educational level, employment status, and partnership status. The Essen Resource Inventory (ERI)13 was applied to evaluate the different resource dimensions of the participants. Besides the calculation of a global score, it allows the assessment of personal resources (PER), social resources (SOR), and structural resources (STR; a detailed description of the 3 resource dimensions as provided by Tagay et al13 is included in the Introduction). The ERI ranges from 0 (little availability) to 3 (high availability) and measures the availability of resources in the last 4 weeks (4-week version) and additionally allows a retrospective assessment of resources 3 years ago (3-year version). Resources can be personal and environmental as trait and state variables and are subject to constant change.21 In the present study, good and very good reliabilities for the subscales PER and SOR and the global score emerged (all Cronbachs-a 0.86 and 0.93). Reliability for the subscale STR was deficient (a ¼ 0.54), results, therefore, have to be interpreted with caution. Sense of coherence was measured using the SOC scale.22 It consists of 13 items that can be answered on a 7-point Likert scale with high values indicating a high SOC. In the present study, the SOC-13 showed a high internal consistency (a ¼ 0.88). Social support was measured using the Social Support Scale (SSS),23 which consists of 22 items that assess social support and integration, the presence of confidants, and satisfaction with social support on a 5-pointy Likert scale with high

values indicating high levels of social support. In the present study, the SSS showed very good reliability (a ¼ 0.96). Healthrelated QOL was measured using the Short Form Health Survey,24 which comprises a mental component scale (MCS) and physical component scale (PCS) with high values indicating a good QOL. For both scales, good reliabilities emerged (MCS: a ¼ 0.83; PCS: a ¼ 0.83).

Subgroups The sample was divided into 3 subgroups based on the time since GAS and study inclusion. Participants in group 1 (n ¼ 48) had received surgery 4 months to 3 years before study participation. Participants in group 2 (n ¼ 62) had received GAS between 3.1 years and 10 years before study inclusion, and participants in group 3 (n ¼ 41) had received surgery 10.1 years to 21.4 years before study inclusion. When splitting the total sample into subgroups, the sample was divided at the 3-year marks. By choosing this cutoff value it was ensured that all participants of group 1 had received GAS 3 years ago or less. Therefore, when filling in the 3-year version of the ERI, group 1 referred to a time before their GAS. For group 1, the comparison of the 2 versions of the ERI thus allowed to investigate differences in available resources before and after GAS. The 10-year mark was chosen as a cutoff between group 2 and group 3 to align sample sizes of the 3 subgroups as much as possible.

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Table 1. Demographic characteristics of the 3 subgroups Group (N ¼ 151þ)

Group 1 (n ¼ 48)

Group 2 (n ¼ 62)

Group 3 (n ¼ 41)

Statistics

Mean

Mean

Mean SD

F

SD

Range

SD

Range

Range

(df) P value

Age (N ¼ 151) 44.27 10.91 22
65 50.47 10.96 25
75 54.15 9.41 38
77 11.84 150 <.001 Time since GAS, years (N ¼ 151) 1.43 0.76 0.3
3.0 5.85 2.18 3.1
10.0 12.77 2.97 10.1
21.4 316.91 150 <.001 Statistics

Education (N ¼ 148) “High” “Moderate/low” Employment (N ¼ 136) “Engaged” “Not engaged” Partnership (N ¼ 144) Single Not single

n

%

n

%

n

%

25 23

52.1 47.9

33 28

53.2 45.2

20 19

48.8 46.6

28 16

58.3 33.3

38 21

61.3 33.9

22 18

53.7 43.9

24 24

50.0 50.0

33 29

53.2 46.8

21 20

51.2 48.8

c2

(df)

P value

0.09

2

.958

1.01

2

.604

0.12

2

.943

GAS ¼ gender-affirming surgery. Group 1: participants with GAS 4 months to 3 years ago; Group 2: participants with GAS 3.1
10 years ago; and Group 3: participants with GAS 10.1
21.4 years ago. P < .05 in bold. “High” education: university diploma or university entrance diploma; “Moderate/low” education: general certificate of secondary education or no graduation; “Engaged”: student, part-time or full-time employment; “Not engaged”: unemployed, certified unfit for work, retired; þ: for 7 participants, information about time because GAS was missing, they were, therefore, excluded from subgroup analyses.

Statistical Analyses Statistical analyses were conducted using PASW Statistics 22 for Windows (SPSS, Chicago, IL, USA). Continuous variables were expressed as means and SDs. Qualitative variables were expressed as percentages. Normality of the data was tested using Shapiro-Wilk tests. Homogeneity of variance was tested using Levene tests. Nonparametric statistics were used if assumptions for parametric testing were violated. Internal consistency within the scales used was assessed through Cronbach’s a. Statistical significance was accepted at the 2-tailed a ¼ 0.05 significance level. Bonferroni corrections were applied to control for multiple testing. Effect-sizes were reported as Cohens d if applicable and were considered as small (d  0.2), medium (d ¼ 0.5), and large (d  0.8) effects according to the convention.25 Test-by-test deletion was used to deal with missing data. Participants who could not be classified into one of the subgroups due to missing information about the date of GAS procedures were excluded from subgroup analyses (n ¼ 7). The numbers of datasets included in each of the respective analyses are indicated accordingly. Group effects were analyzed using Kruskal-Wallis tests. Post hoc tests were performed with MannWhitney tests. The 2 versions of ERI were examined with Wilcoxon signed-rank tests for the 3 subgroups, respectively. The total sample was compared to a reference group of the respective test manual using 1-sample t-tests due to a lack of an adequate nonparametric alternative and as the size of the total sample (>150) was considered large enough to assume normality of the data.

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RESULTS Sample Characteristics In total, 158 persons sent back the questionnaires. This represents a response rate of 42%. The mean age of the study participants was 49.8 years (SD ¼ 11.1; range 22
77 years). The mean interval between GAS and study participation was 6.6 years (SD ¼ 5.0; range 4 months to 21.4 years). Demographic information about the 3 subgroups is presented in Table 1.

Group Differences Results of the subgroup analyses of the ERI are detailed in Table 2. There was a significant increase in PER, SOR, STR, and ERI global score from 3 years to 4 weeks for group 1 (all P < .013). For group 2 and group 3, no differences between the 4-week version and the 3-year version emerged on neither of the scales. When looking at ERI mean scores descriptively, group 2 and group 3 showed higher ERI 3-year scores than group 1, whereas ERI 4-week scores were similar for all 3 groups. For SOC (see Table 3), a significant group effect became evident (P ¼ .035), although no significant group differences could be found in pairwise post hoc analyses after correcting for multiple testing (all P > .017). No group differences in SSS scores could be seen (P ¼ .990). The 3 subgroups did not differ regarding PCS (P ¼ .100), whereas a group effect was detected for MCS (P ¼ .041). Pairwise post hoc analyses revealed that group 1 showed a significantly lower mental QOL than group 3 (P ¼ .017), whereas group 2 did not differ from group 1 or

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Table 2. Comparisons of the ERI subscales 3 years ago and in the last 4 weeks are presented for the 3 subgroups separately

Group 1 mean (SD)

Group 2 mean (SD)

Group 3 mean (SD)

PER 3 years ago

PER in the last 4 weeks

SOR 3 years ago

SOR in the last 4 weeks

STR 3 years ago

STR in the last 4 weeks

ERI global 3 years ago

ERI global in the last 4 weeks

N ¼ 42 1.65 (0.42) z ¼
4.04 P < .001* d ¼ 0.66 N ¼ 50 1.98 (0.44) z ¼
1.47 P ¼ .142 d ¼ 0.09 N ¼ 34 2.00 (0.50) z ¼
2.19 P ¼ .029 d ¼ 0.10

N ¼ 43 1.93 (0.43)

N ¼ 47 2.09 (0.70) z ¼
2.50 P [ .012* d ¼ 0.38 N ¼ 59 2.25 (0.70) z ¼
1.82 P ¼ .068 d ¼ 0.10 N ¼ 39 2.22 (0.76) z ¼
0.63 P ¼ .527 d ¼ 0.01

N ¼ 47 2.30 (0.73)

N ¼ 47 1.46 (0.63) z ¼
2.84 P [ .005* d ¼ 0.37 N ¼ 58 1.59 (0.66) z ¼
2.34 P ¼ .020 d ¼ 0.15 N ¼ 38 1.77 (0.73) z ¼
0.69 P ¼ .490 d ¼ 0.04

N ¼ 47 1.70 (0.68)

N ¼ 41 1.70 (0.42) z ¼
3.91 P < .001* d ¼ 0.63 N ¼ 49 1.99 (0.42) z ¼
1.53 P ¼ .127 d ¼ 0.10 N ¼ 33 2.00 (0.50) z ¼
2.12 P ¼ .034 d ¼ 0.10

N ¼ 42 1.96 (0.41)

N ¼ 50 2.02 (0.42)

N ¼ 33 2.05 (0.49)

N ¼ 59 2.32 (0.69)

N ¼ 39 2.23 (0.77)

N ¼ 58 1.69 (0.64)

N ¼ 38 1.80 (0.76)

N ¼ 49 2.03 (0.41)

N ¼ 33 2.05 (0.51)

Significance threshold was adjusted for multiple testing by P ¼ a/4 ¼ .013. Group 1: participants with gender-affirming surgery (GAS) 4 months to 3 years ago; Group 2: participants with GAS 3.1
10 years ago; Group 3: participants with GAS 10.1
21.4 years ago. d ¼ effect size Cohen’s d; ERI ¼ Essen Resource Inventory; PER ¼ Personal Resources; SOR ¼ Social Resources; STR ¼ Structural Resources; z ¼ test statistic Wilcoxon signed-rank test. *P  .013 in bold.

Breidenstein et al

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Table 3. Subgroup comparisons of QOL, social support, and SOC

Group 1 mean (SD) Group 2 mean (SD) Group 3 mean (SD) Statistics

SF-12 MCS

SF-12 PCS

SSS

SOC Scale

N ¼ 41 45.43 (12.55) N ¼ 57 46.68 (12.27) N ¼ 39 51.08 (11.74) H(df) ¼ 6.37 (2) P ¼ .041 G1
G2: U ¼ 1,107.0 Pþ ¼ .658 d ¼ 0.10 G1
G3 U ¼ 551.0 PD [ .017* d ¼ 0.47 G2
G3 U ¼ 840.5 Pþ ¼ .043 d ¼ 0.37

N ¼ 41 51.08 (8.87) N ¼ 57 47.06 (11.06) N ¼ 39 45.25 (10.58) H(df) ¼ 4.63 (2) P ¼ .099

N ¼ 46 3.99 (0.98) N ¼ 61 4.10 (0.75) N ¼ 41 3.97 (0.96) H(df) ¼ 0.02 (2) P ¼ .990

N ¼ 47 4.71 (1.29) N ¼ 58 4.94 (0.96) N ¼ 40 5.37 (1.04) H(df) ¼ 6.52 (2) P ¼ .038 G1
G2: U ¼ 1,267.0 Pþ ¼ .536 d ¼ 0.20 G1
G3 U ¼ 667.5 Pþ ¼ .020 d ¼ 0.57 G2
G3 U ¼ 869.0 Pþ ¼ .035 d ¼ 0.43

Group 1 (G1): participants with gender-affirming surgery (GAS) 4 months to 3 years ago; Group 2 (G2): participants with GAS 3.1
10 years ago; Group 3: participants with GAS 10.1
21.4 years ago. d ¼ effect size Cohen’s d; H ¼ test statistic Kruskal-Wallis test; MCS ¼ mental component scale; PCS ¼ physical component scale; Pþ ¼ significance threshold was adjusted for multiple testing by pþ ¼ a/3 ¼ .017; QOL ¼ quality of life; SF-12 ¼ Short Form Health Survey; SOC ¼ Sense of Coherence Scale; SSS ¼ Social Support Scale; U ¼ test statistic Mann-Whitney U test. *Pþ  .017 in bold.

group 3 after correcting for multiple testing (both P > .017). The results are detailed in Table 3.

Comparison Study Sample with Control Group Study participants were compared to control women of the normative samples reported in the respective test manuals. Trans women showed significantly lower scores on all ERI dimensions (all P < .05). No differences in SOC (P ¼ .727) and SSS (P ¼ .271) emerged. No group differences were detected in physical QOL (P ¼ .060), whereas trans women showed a significantly lower mental QOL when compared to controls (P < .05). Results are detailed in Table 4.

DISCUSSION The present study aimed to systematically investigate, we believe for the first time, the availability of different resources and QOL in trans women following GAS. Knowledge about QOL and the availability of psychosocial resources in trans women in the mid- and long-term after GAS is scarce. Trans women who had received GAS within the last 3 years showed an increase in resources when comparing ERI 3-year scores (presurgery) with ERI 4-week scores (postsurgery). No such differences emerged for trans women whose GAS dated back more than 3 years. Compared to normative data from non-trans women, trans women scored significantly lower on all dimensions of the ERI but not in measures of SSS or SOC. Compared to healthy, non-trans women, mental QOL was significantly impaired in trans women, whereas no differences in physical QOL emerged. J Sex Med 2019;16:1672e1680

Trans Women Subgroup Differences in Psychosocial Resources and QOL Interestingly, when comparing ERI scores 3 years ago with scores in the last 4 weeks, trans women who had received GAS within the last 3 years (group 1) showed an increase in resources, whereas trans women who had had GAS >3 years ago (group 2 and group 3) did not show such differences in available resources. However, it should be noted that group 2 and group 3 scored higher than group 1 on nearly all dimensions of the ERI. These findings hint toward the importance of GAS for the improvement of psychosocial resources. Possibly, trans women who had received GAS >3 years ago have fully adjusted to their surgical transition, therefore showing higher scores than those who had received GAS <3 years ago. This could imply that available resources improve mainly in the first 3 years after GAS and then stabilize. Existing research has shown an enhanced well-being and better QOL following GAS7,9 that might possibly stimulate the development of psychosocial resources. Tugade and Frederickson26 discuss the effects of positive emotions on the development of resources and coping strategies. The authors outline that positive emotions can broaden a person’s thought and action repertoire and may enhance personal resources and coping strategies. In line with this, the improvement of available resources following GAS in the current study might be due to an elevated mood and well-being after the physical adaptation of the body to gender identity. In the long-term, this enhanced availability of resources can positively influence QOL. In accordance with this, several studies have found a positive association of QOL and psychosocial resources.6,16,17 Still, the causal

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Table 4. Comparisons between total study sample in the last 4 weeks and controls regarding measures of psychosocial resources and QOL

Trans mean (SD) Controls mean (SD) t P d

PER

SOR

STR

ERI global

SSS

SOC

Mental QOL

Physical QOL

2.01 (0.44)

2.28 (0.73)

1.71 (0.69)

2.01 (0.43)

3.99 (0.91)

4.97 (1.11)

47.70 (12.22)

47.31 (10.86)

2.09 (0.39)

2.47 (0.63)

2.03 (0.58)

2.14 (0.37)

3.91 (0.71)

5.00 (0.89)

52.25 (8.10)

49.03 (9.35)


3.14 .001* 0.28


5.50 <.001* 0.50


3.13 .001* 0.33

1.10 .271 0.10


0.35 .727 0.03


4.36 <.001* 0.45


1.89 .060 0.17


1.97 .032* 0.19

Trans group was compared to a reference group of healthy women reported in the respective test manuals. d ¼ effect size Cohen’s d; ERI ¼ Essen Resource Inventory; PER ¼ personal resources; QOL ¼ quality of life; SOC ¼ Sense of Coherence; SOR ¼ social resources; SSS ¼ Social Support Scale; STR ¼ structural resources; t ¼ one-sample t-tests. *P < .05 in bold.

relationships and possible moderating effects of gender-affirming procedures, psychosocial resources, and QOL in trans women remain to be investigated. When analyzing group differences in the last 4 weeks, the 3 subgroups did not differ regarding their perceived social support and SOC. Similarly, when looking at the mean scores of the ERI in the last 4 weeks, no appreciable differences among the 3 subgroups could be detected either. These findings again indicate that the availability of resources improves shortly after GAS and stabilizes over time. The study sample showed a wide age range (22
77 years). There was a significant negative correlation between age and physical QOL and a significant positive correlation between age and mental QOL. In line with this, when looking at mental QOL of the 3 subgroups separately, group 3 showed a significantly higher QOL than group 1. Importantly, participants of group 3 were significantly older than group 1. However, as research investigating age effects on QOL in large epidemiologic studies24,27 has observed a decrease in mental QOL with older age, the observed differences are unlikely to be caused by the existing age difference. Possibly, the observed effect results from an interaction of an improved QOL following GAS enhancing the availability of resources, which again improves QOL. This may lead to a long-term improvement of mental QOL even many years after the completion of gender-affirming procedures. In contrast, physical QOL did not differ between the subgroups despite significant age differences between the groups. High levels of physical QOL emerged for all trans women. As physical QOL has been shown to decrease with older age in the general population,24,27 the completion of the transition might function as a protective factor buffering the negative effects of aging, hereby leading to a high physical QOL even in older trans women.

Study Sample vs Normative Sample of Non-Trans Women One aim of this study was to test if QOL and resources in trans women following GAS (ie, right after and even many years from their surgical transition) are comparable to healthy, agematched, non-trans women. An increase in resources was detected in trans women who had received GAS within the last 3

years when comparing ERI 3-year scores (presurgery) with ERI 4-week scores (postsurgery). This hints toward a positive effect of GAS on QOL. However, the total group of trans women showed significantly lower scores on all ERI dimensions in the last 4 weeks when compared to controls. Accordingly, trans women showed a lower mental QOL than the control sample. The present findings correspond to research that has shown a significantly lower QOL in trans women when compared to controls,8,9 although these study samples included trans women before GAS9 or at different stages in their transition.8 As QOL has been shown to improve after GAS,7,9 the low levels of mental QOL in the current sample are notable. Furthermore, high levels of social support emerged for the SSS. Existing research has indicated the importance of social support on QOL in trans women,14,15 whereas trans women perceive themselves to receive less social support than trans men15 and non-trans women.16 Despite the observed high levels of social support, mental QOL was reduced in the current sample. One possible explanation for this finding might be a higher prevalence of psychiatric comorbidities in the current sample. Indeed, higher levels of psychiatric comorbidities have been found in trans women14,28,29 and in trans men and women, as reported in a systematic review by Dhejne et al.30 No differences between trans women and controls occurred regarding physical QOL. This is in line with research reporting good physical QOL in trans women.5,6 As all study participants had received GAS at least 4 months ago, consequences of surgery as pain or physical limitations that could influence physical QOL should be minimal. This study focuses on trans women only. Existing research on QOL in trans men has revealed a similar QOL when compared to non-trans men.31,32 Other studies have shown a reduced QOL in trans men, although trans men who received hormonal therapy showed an improved QOL.6,33 Trans women may to a higher degree than trans men suffer from discrimination, less acceptance by family members,15 and less perceived social support15,16 that could negatively influence QOL. It can, therefore, be hypothesized that available resources and QOL in trans men will be comparable or even higher than in trans women in the current sample. J Sex Med 2019;16:1672e1680

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Limitations and Future Directions The major limitation to this study is its cross-sectional design. To investigate the availability of different resources and QOL in trans women in the mid- and long-term after GAS, the study sample was divided into 3 different subgroups. However, in this design, no information about the long-term development of an individual person is available. Furthermore, it is important to mention that the availability of resources 3 years ago was assessed retrospectively using the ERI. Therefore, confounding elements, such as a recall bias, cannot be ruled out.34 Another limitation to the study is the representativeness of the sample. About 42% of the contacted persons participated in the study. Unfortunately, insufficient information about the demographic characteristics of the nonrespondents was available. Therefore, no conclusions about demographic properties characterizing the responding vs nonresponding persons can be drawn. When interpreting the present study, it should be considered that the present results may be influenced by a selection bias. Furthermore, only trans women were investigated. This was caused by the fact that participants were recruited at the local clinic that offers male-tofemale GAS exclusively. Thus, a generalization of the present results to the total group of trans people is not possible. Future studies should, therefore, incorporate a prospective longitudinal design and a large sample of trans men and trans women to shed more light on the individual development of resources and QOL in trans people throughout their transition.

CONCLUSION The present study is the first to systematically investigate the availability of different psychosocial resource dimensions and QOL in trans women after GAS. The study allows the comparison of recently transitioned women with those who have received surgery >21 years ago. This study indicates that different psychosocial resources improve in the first 3 years after GAS and then stabilize. Still, it becomes obvious that compared to the general population trans women have a lower availability of resources and a lower mental QOL. Even for trans women who may have completed their transition a long time ago, the offering of specialized counseling or medical services can have a highly beneficial potential in supporting personal growth and the development of psychosocial resources thereby enhancing QOL and well-being.

ACKNOWLEDGMENTS The authors would like to thank our participants for their support and efforts. Further, we would like to thank Melav Bari, Rebecca Heinrich, Matthias Lühr, Julie Ortmann, Jasmin Steinbach, and Kristina Westrich for their assistance in study implementation. Corresponding Author: Anja Breidenstein, PhD, Department of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen Virchowstr. 174, 45147 Essen, Germany. Tel: J Sex Med 2019;16:1672e1680

0049-201-7227326; Fax: 0049-201-7227305; [email protected]

E-mail: anja.

Conflict of Interest: None. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

STATEMENT OF AUTHORSHIP Category 1 (a) Conception and design Anja Breidenstein; Sefik Tagay; Jochen Hess (b) Acquisition of Data Anja Breidenstein; Jochen Hess; Sefik Tagay (c) Analysis and Interpretation of Data Anja Breidenstein; Sefik Tagay; Jochen Hess; Martin Teufel; Boris Hadaschik Category 2 (a) Drafting the Article Anja Breidenstein; Sefik Tagay; Jochen Hess; Martin Teufel (b) Revising it for Intellectual Content Anja Breidenstein; Sefik Tagay; Jochen Hess; Martin Teufel; Boris Hadaschik Category 3 (a) Final Approval of the Completed Article Anja Breidenstein; Sefik Tagay; Jochen Hess; Martin Teufel; Boris Hadaschik

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