Exploring gender euphoria in a sample of transgender and gender diverse patients at two U.S. urban community health centers

Transgender and gender diverse (TGD) people are affected by mental health inequities. Gender euphoria-positive emotions or joy in gender-may be associated with positive mental health. Between February 2019-July 2021, we surveyed 2,165 adult TGD patients (median age = 28 years; 29.2 % people of color; 29.6 % nonbinary; 81.0 % taking hormones) evaluating gender euphoria and mental health. Overall, 35.0 % self-reported gender euphoria, 50.9 % gender dysphoria, 23.5 % alcohol misuse, and 44.5 % resilience. Gender euphoria differed by race, gender, insurance, and hormone use, and was associated with reduced gender dysphoria (adjusted Odds Ratio[aOR] = 0.58; 95 % confidence interval [95 %CI] = 0.47-0.72) and alcohol misuse (aOR = 0.75; 95 %CI = 0.60-0.95), and increased resilience (aOR = 1.31; 95 %CI = 1.07-1.61). The construct of gender euphoria may be a promising mental health target.


Introduction
Transgender and gender diverse (TGD) populations are affected by mental health inequities, including high rates of psychological distress and substance use that far surpass those in cisgender populations (Hanna et al., 2019;Hughes et al., 2021;Hughto et al., 2021;Lipson et al., 2019;Reisner et al., 2015).A deficits-based framing is often used to investigate mental health vulnerabilities that result from being marginalized as a TGD person.Research has historically focused on gender dysphoria, a Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) psychiatric diagnosis which refers to significant distress and/or impairment in daily functioning due to having a gender that is incongruent with assigned sex at birth (American Psychiatric Association, 2013).Gender dysphoria is often a prerequisite for access to gender-affirming care (Coleman et al., 2012) and research highlights its co-morbidities with other mental health conditions (Dhejne et al., 2016).Yet, an overemphasis on gender dysphoria, medicalized narratives of distress, and related constructs such as incongruence may be harmful for TGD people by reinforcing stigma and associations with mental health disorders (Ashley, 2021).
In a qualitative study to inform clinical research, TGD adults have called for research on resilience and health-enhancing factors for mental health: "There's like a scale for depression… there's no inverse of that, you know what I mean?There's no elation… I want to know how happy people are, you know?" (Asquith et al., 2021) Gender euphoria is a concept often discussed in TGD communities that has only recently been considered by the research community (Ashley, 2019;Austin et al., 2022;Beischel et al., 2022;Bradford et al., 2021;Jacobsen and Devor, 2022).Although there is no agreed upon definition (Beischel et al., 2022), gender euphoria generally refers to positive emotions, such as happiness or intense joy and feelings of calm, resulting from gender self-actualization, affirmation of gender identity or expression, and/or achievement of desired transgender milestones (Austin et al., 2022;Beischel et al., 2022).In a mixed-methods study of 47 TGD individuals, Beischel et al. (2022) refer to it as "a joyful feeling of rightness in one's gender/sex" (p 281) (Beischel et al., 2022).Gender euphoria offers a resilience-related concept that may facilitate positive mental health outcomes for TGD people and resonates with community experiences.It differs from other constructs such as gender congruence focused on mitigating distress or conflict with identity.
This study aimed to explore gender euphoria in a cohort of TGD primary care patients at two community health centers, examine the correlates of gender euphoria, and evaluate the association of gender euphoria and several mental health-related outcomes.First, we anticipated that there would be substantial heterogeneity in gender euphoria by sociodemographic and medical gender affirmation characteristics but did not have specific hypotheses given the exploratory nature of the study.Second, we hypothesized that gender euphoria would be associated with reduced odds of gender dysphoria, psychological distress, and alcohol misuse, and increased odds of resilience, when accounting for each of the other mental health-related variables.

Participants and procedures
This study leverages self-reported baseline data from 2192 adult TGD patients who were enrolled between February 2019-July 2021 into the LEGACY cohort, a multisite study of TGD patients receiving primary care at community health centers in Boston, MA and New York City, NY (Reisner et al., 2021).The survey included questions on sociodemographics, gender affirmation, gender dysphoria, psychological distress, substance use, and resilience.Participants underwent an electronic informed consent process and the research was approved by the Institutional Review Board at Fenway Health.

Gender euphoria
Gender euphoria was assessed with two survey items, drawn from a previously validated scale of gender congruence (Kozee et al., 2012), that reflected experiences of happiness and acceptance as proxy measures for gender euphoria.The two scale items were selected with input from TGD researchers and community members.The questions asked participants to indicate the response that best described their experience in the past two weeks: "I am happy that I have the gender identity that I do" and "I have accepted my gender identity".Response options ranged from 1 = strongly disagree to 5 = strongly agree.Items were significantly correlated (Pearson r = 0.58; p < 0.0001) with acceptable internal consistency (standardized α = 0.74).Items were summed and a binary variable for high vs low gender euphoria was operationalized as above the sample median (score > 9) vs at or below (score =< 9).(Kozee et al., 2012)

Sociodemographics and medical gender affirmation
Sociodemographic characteristics were age group in years (18-24, 25-29, 30-39, 40-71), race (Black, Latinx, Multiracial, Asian, Another Race, White), Latinx ethnicity (yes, no), gender identity (transgender man, transgender woman, nonbinary assigned female sex at birth [AFAB], nonbinary assigned male sex at birth [AMAB]), health insurance (private, public, uninsured), and education (college degree, no college degree).Gender-affirming hormone therapy (I have taken hormones, have not taken hormones but am interested in taking them, I have not taken hormones and I do not want them) and gender-affirming surgery (any, none) were assessed.

Mental health-related variables
Gender dysphoria was measured using the 12-item Utrecht Gender Dysphoria Scale (Cohen-Kettenis and van Goozen, 1997).Sample items were: "I feel strongly that my gender identity is different than my assigned sex at birth" and "I feel unhappy every time someone treats me as my assigned sex at birth".Response options ranged from 1 = disagree completely to 5 = agree completely.Items were summed and scores ranged from 1-60 (standardized α = 0.81 in the sample).Participants scoring above the sample median (score > 49) were coded as high dysphoria, those scoring at or below the median (score =< 49) as low dysphoria in the absence of a validated cut-point.Psychological distress was assessed with the Kessler-6 (K-6) (standardized α = 0.89 in the sample) (Kessler et al., 2003(Kessler et al., , 2010)).The validated cut-point score of >=13 was used to operationalize clinically significant elevations in psychological distress consistent with DSM diagnoses for depression and anxiety disorders (Kessler et al., 2003(Kessler et al., , 2010)).
Alcohol use was measured with the Alcohol Use Disorder Identification Test (AUDIT-C) (standardized α = 0.68 in the sample) where a score >=3 indicated hazardous drinking or alcohol misuse indicating a positive screen for potential alcohol use disorder (Bradley et al., 2007;Bush et al., 1998).
The 6-item Brief Resilience Scale assessed resilience (standardized α = 0.89 in the sample) (Smith et al., 2008).Example items: "I tend to bounce back quickly after hard times" and "It does not take me long to recover from a stressful event."The three reverse-scale items were recoded, and all items were summed.High (score > 18) and low (score =< 18) resilience was operationalized as above vs at or below the sample median given no validated cut-point exists for the scale.

Statistical analysis
The analytic sample was restricted to patients with non-missing gender euphoria data (n = 2165; 98.8 % of the total baseline sample).Given the low proportion of missing data across all other variables (<5.0 %), a complete case analysis was conducted.Descriptive statistics for the sample overall and stratified by high and low gender euphoria were calculated.Bivariate logistic regression models regressed high vs low gender euphoria on sociodemographics, medical gender affirmation, gender dysphoria, psychological distress, hazardous alcohol use, and resilience.A multivariable logistic regression model was then fit examining the correlates of high vs low gender euphoria with sociodemographic variables and medical gender affirmation as independent variables.
Next, four multivariable logistic regression models were fit to examine whether high vs low gender euphoria (primary exposure effect) was associated with gender dysphoria, psychological distress, alcohol misuse, and high resilience, adjusting for sociodemographics, medical gender affirmation, and the other mental health variables (secondary effects).Secondary effects were estimated to isolate the primary effect of high vs low gender euphoria.An area-proportional Venn diagram (Chen and Boutros, 2011) was created to visualize the overlapping percentages in gender euphoria, gender dysphoria, psychological distress, alcohol misuse, and resilience.Statistical significance was pre-determined at the alpha 0.05-level.Analyses were conducted in R statistical software.

Sociodemographic and medical gender affirmation correlates of gender euphoria
In bivariate comparisons, the odds of high vs low gender euphoria significantly differed by age, race, ethnicity, gender identity, insurance, hormones, surgery, gender dysphoria, psychological distress, alcohol

Associations of gender euphoria and mental health
Fig. 1 displays a proportional Venn diagram of high gender euphoria, gender dysphoria, psychological distress, alcohol misuse, and resilience constructs.Overlapping and non-overlapping percentages show both commonality and distinctness across constructs.The Venn diagram analysis indicated a 14 % overlap (commonality) between the constructs of gender euphoria (yellow color) and dysphoria (blue color).

Discussion
In this study of adult TGD primary care patients, more than one-third (35.0 %) had high gender euphoria, responding that they "strongly agreed" with gender euphoria items.Gender euphoria prevalence in this sample differed by race, gender identity, health insurance, and hormone status in TGD patients.Self-identified Black compared with White individuals, transgender women and nonbinary AFAB compared with transgender men, and publicly relative to privately insured patients had higher gender euphoria.Given that gender euphoria differed by race and gender in this sample, future research may benefit from applying an intersectional framework (Wesp et al., 2019) to consider joint processes of identity affirmation, such as affirmation of both racial and gender identities.Hormone status, specifically wanting but not having taken hormones, was associated with lower gender euphoria in TGD patients.The reasons why patients interested in hormones had not taken them were not ascertained.However, this finding highlights the importance of minimizing barriers for TGD patients interested in pursuing medical gender affirmation as a possible route to increase gender euphoria and positive mental health.
Prior research suggests the interconnectedness of gender euphoria, gender dysphoria, and mental health (Jacobsen and Devor, 2022), but "there is little consensus as to the relationship between dysphoria and euphoria, both conceptually and experientially" (p 276) (Beischel et al., 2022).Corroborating previous inquiries (Austin et al., 2022;Beischel et al., 2022;Jacobsen and Devor, 2022), this study found that gender euphoria and gender dysphoria have a complex relationship.In the current sample, high gender euphoria was associated with lower levels of gender dysphoria.Gender euphoria was also independently associated with reduced alcohol misuse and higher resilience, after adjusting for gender dysphoria.Consistent with qualitative research (Beischel et al., 2022), rather than being simply the opposite of gender dysphoria, gender euphoria was a distinct and independent construct.Gender euphoria was not associated with elevated psychological distress in this sample when accounting for levels of current gender dysphoria.Future research is needed to measure and evaluate gender euphoria alongside gender dysphoria in TGD people across a range of both internalizing (e. g., psychological distress) and externalizing (e.g., substance misuse) mental health outcomes.

Limitations
Several limitations are important to consider in interpreting study findings.Ours was a clinical sample at community health centers specializing in gender-affirming care which may not generalize to other centers or regions of the US.Results may not translate for TGD people who do not access care.Our sample may have higher euphoria than other samples given all are connected to clinical care.There are no validated measures of gender euphoria in the current research literature.Our crude measure of gender euphoria was comprised of two items which were selected by TGD researchers and community members.The measure serves as only a proxy for gender euphoria.Prior qualitative research has described gender euphoria as having external or physical, internal or psychological, and social dimensions (Beischel et al., 2022).Additional research is needed to develop and validate measures to robustly operationalize gender euphoria across multiple dimensions.In the meantime, this study offers preliminary and exploratory data supporting the importance of gender euphoria as a construct for future research in TGD mental health.

Conclusion
This study found the distribution of gender euphoria differed by key sociodemographics and hormone status and was generally associated with better mental health.Gender euphoria may be a target for future clinical and public health interventions seeking to increase resilience while reducing psychological distress, gender dysphoria, and alcohol misuse; future longitudinal research is needed.Consistent with prior qualitative research (Jacobsen and Devor, 2022), gender euphoria may be as or more important for TGD people than dysphoric negative gender-related emotions.Investigating resiliency, resistance to gender oppression, and how TGD people experience positive emotions, flourish, and thrive in relation to experiences of gender represents an important next step to inform clinical care and optimize mental health.Developing and validating measures of gender euphoria is crucial to better characterize this promising mental health construct.

Table 1
Sociodemographics, medical gender affirmation, and mental health stratified by high and low gender euphoria (N = 2165): descriptive statistics and bivariate models.Definitions of "high" and "low" gender euphoria are based on whether a participant's score was above vs at or below the sample median.Bolding indicates statistical significance at α = 0.05.Gender dysphoria, psychological distress, alcohol misuse, and resilience were not included in the multivariable model of gender euphoria.IQR = interquartile range.AFAB = assigned female sex at birth.AMAB = assigned male sex at birth.OR = Odds Ratio.95 % CI = 95 % Confidence Interval.AUDIT-C = Alcohol Use Disorder Identification Test.Percentages may sum to more than 100 % due to rounding.misuse,andresilience(Table1).In a multivariable model regressing high vs low gender euphoria on sociodemographics and medical gender affirmation variables (Table2, Model 1), there were elevated odds of high gender euphoria for patients self-identified as Black vs White (adjusted odds ratio[aOR] = 1.66; 95 % Confidence Interval[95 % CI] =

Table 2
Multivariable models for high vs low gender euphoria and mental health-related outcomes: gender dysphoria, psychological distress, alcohol misuse, and resilience.