Chapter 9 274 by the possible effects of stress about access to care compared to previous studies, but a form of bias could not be ruled out. Secondly, as displayed in Figure 9.5, during GAHT use transgender persons can also take other steps in their transition. These include changing their name, legal gender marker, appearance, or voice (Glynn et al., 2016; Pollitt et al., 2021), which can improve psychosocial well-being, reduce minority stress and improve mental well-being (Scheim et al., 2020). However, the works in this thesis have not taken into account social transition steps or minority stress during OC and GAHT use. Studies thus far show no significant difference between TM and TF in minority stress after 6 months of GAHT (Collet et al., 2023). One could might hypothesize that effects of social transition steps are similar during the first year of masculinizing and feminizing GAHT, but studies on social transition steps and well-being are still lacking. Social transition steps and minority stress were not accounted for in the works in this thesis, and could therefore have imposed a bias in our studies. Figure 9.5. Illustration of the possible transition steps in gender-affirming care, and the overlap of psychological, biological, and social changes one could experience in this transition. Mastectomy surgeries can happen irrespective of gender-affirming hormone use, but other surgeries (e.g. gonadectomy, genital surgery) can be performed after 12 months of GAHT. The role of social transition steps and surgical changes was mostly not accounted for in this thesis, creating a possible bias in our study outcomes. Created using Biorender.com. 3.4. Assessment of depressive symptomatology The main approach to measuring depression in this thesis was through assessment of the severity of various depressive symptoms using the
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