Chapter 3 86 4. Discussion This study aimed to assess the symptom profile of depression in transgender persons at the start of GAHT, and to assess possible changes in the symptom profile and severity during the first 12 months of GAHT. Depressive symptoms show four clusters: mood-, anxiety-, lethargy-, and somatic symptoms. After 3 and 12 months of GAHT use, the overall cohort reports no significant changes in total IDS-SR scores, nor in any of the subscales. TF participants show a significantly larger increase in the total IDS-SR scores compared to TM participants after 3- and 12 months of GAHT. The TM participants showed a modest but significant temporary decrease in lethargy-related symptoms after 3 months of GAHT. The TF participants showed a modest but significant increase in mood-related symptoms after 12 months of GAHT. The clusters found in the EFA analyses differ from the clusters as originally found in the IDS-SR by Rush et al. (1996) and from clusters previously found in a cisgender Dutch population (Wardenaar et al., 2010), which showed clusters around mood and cognition, anxiety and somatic complaints and sleep. This may be due to specific adversities that transgender persons face, such as minority stress, low social support, and discrimination. A possible role of minority stress is seen in the cluster of anxiety symptoms, where anxious feelings and panic show strong associations with sensitivity to rejection and low self-image. Notably, we did not find a significant decrease in depressive symptoms in the overall cohort after start of GAHT, in contrast with previous studies (Costa & Colizzi, 2016; Doyle et al., 2023). This discrepancy could have numerous explanations. Firstly, mood may be influenced by the timing of the baseline measurement: in the ENIGI and RESTED cohorts, the participants already knew they were going to start GAHT soon at the baseline measurement, and stress or excitement about starting GAHT could have affected their mood. Secondly, the IDS-SR data of this study was not accessible to healthcare providers, whereas study data from previous studies was often obtained from clinical care. This addresses a concern that was previously noted (Baker et al., 2021), which is that participants could provide socially desirable answers when they know that their healthcare providers can access their answers, out of fear of losing access to GAHT.
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