The Relationship between Gender Affirming Medical Interventions and Social Anxiety Among Transgender or Gender Non-Conforming Individuals

Gender affirming medical interventions (GAMI) are interventions that some, but not all, transgender or gender non-conforming (TGNC) individuals seek in order to bring their primary and secondary sex characteristics in line with their own affirmed gender. These interventions can include hormone treatments, genital surgery, chest surgery, hair removal, tracheal shave or speech therapy. There are a variety of reasons why TGNC individuals seek these interventions; among these, GAMIs may reduce visually apparent gender nonconformity and thus the likelihood of experiencing minority stressors such as discrimination and non-affirmation.

In our study, we examined how social anxiety relates to the utilization of GAMIs. Using a large, cross-sectional survey of TGNC individuals (n= 715), we compared levels of social anxiety between those who had completed a given GAMI, planned on doing it, considered doing it, or had no interest in it. Overwhelmingly, those who had completed GAMIs reported lower social anxiety than those who were planning or considering interventions in the future. In addition, those who were planning or considering GAMIs tended to report higher social anxiety than those who were not interested in interventions, although these findings did vary based on type of intervention and gender identity (i.e., transmasculine or transfeminine). Thus, for those who are interested in a given intervention, having completed that intervention appears to be related to lower social anxiety.

There are several ways in which one could interpret these findings and the nature of the relationship between GAMIs and social anxiety. First, a previous study demonstrated that those who have accessed GAMIs report lower body dissatisfaction compared to those seeking or planning to have them (Testa et al., 2017); therefore, it is possible that among those who do seek GAMIs, an improvement in body satisfaction and comfort also results in decreased anxiety while engaging socially. Additionally, it may be the case that completion of GAMIs reduces the incidence of gender minority stressors (e.g., rejection, discrimination, non-affirmation) by bringing physical appearance in line with binary gender norms; therefore, a reduction in social anxiety may occur as a result of a reduction in experiences of such stressors and an increase of affirmative experiences within social interactions. Another, alternative, explanation for these findings could be that preexisting social anxiety affects individuals’ ability to seek GAMIs in the first place. Those with higher social anxiety who desire GAMIs may find it more difficult to interact with doctors and advocate for themselves to attain these services, thus keeping them “stuck” in the planning or considering phase of the process.

There are multiple important implications of this research for the work of psychologists with clients. First, these findings suggest that promoting access to GAMIs for those TGNC individuals who want them is critical as it may be associated with mental health benefits such as lower social anxiety. Furthermore, social anxiety can impair individuals by making it difficult for them to attain social support, which we know can be highly influential for the overall mental health of gender minorities (Budge, Adelson, & Howard, 2013). Therefore, it is important for clinicians not only to provide gender-affirming care for TGNC individuals but to actively support clients seeking these interventions. Additionally, when working with clients who may already experience social anxiety that prevents them from taking steps to access the GAMIs they desire, therapists should consider incorporating social anxiety-specific treatment into therapy in order to facilitate clients’ access to these interventions. On a broader scope, as we understand more and more about the impact GAMIs can have on the physical and mental health of individuals who desire them, we have a responsibility as psychologists to advocate for access to these interventions and be supportive of individuals who are seeking them.

Reference Article

Butler, R. M., Horenstein, A., Gitlin, M., Testa, R. J., Kaplan, S. C., Swee, M. B., & Heimberg, R. G. (2019). Social anxiety among transgender and gender nonconforming individuals: The role of gender-affirming medical interventions. Journal of Abnormal Psychology, 128, 25-31.

Discussion Questions

  1. What are some steps and actions psychologists can take to be advocates for TGNC communities beyond their work with individual clients? How can we support TGNC individuals through our research and other work?
  2. How can psychologists assess for and treat social anxiety and other mental health concerns in a way that is sensitive to gender minority stress? What are some of the most important considerations when working with TGNC clients who may experience daily stigmatization and other forms of social stress?

About the Authors

Rachel Butler, M.A. is a 4th year doctoral student in the Temple University Clinical Psychology Ph.D. program. Her research focuses on evidence-based interventions for social anxiety and eating disorders. In particular, she is interested in the application of exposure-based interventions to novel populations.



Arielle Horenstein, M.A. is a 5th year doctoral candidate in the Temple University Clinical Psychology Ph.D. program. Her research focuses on the complex relationship between anxiety and physical health, including understanding anxiety-related mechanisms of medical care utilization, medication adherence, and other health behaviors.


References Cited

Budge, S. L., Adelson, J. L., & Howard, K. A. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81, 545–557.

Testa, R. J., Rider, G. N., Haug, N. A., & Balsam, K. F. (2017). Gender confirming medical interventions and eating disorder symptoms among transgender individuals. Health Psychology, 36, 927–936. https://doi .org/10.1037/hea0000497