Abstract
Purpose:
Binding, packing, using stand-to-pee (STP) devices, and tucking are nonhormonal, nonsurgical gender-affirming body modifications (GABMs) that are used to affirm gender expression. This study sought to describe the sociodemographic characteristics of and side effects experienced by those using GABMs.
Methods:
We conducted a cross-sectional study of The Population Research in Identity and Disparities for Equality Study participants who completed the 2023 Annual Questionnaire. Data on sociodemographics and self-reported side effects were collected and analyzed using descriptive statistics.
Results:
Of 6296 participants, 1694 reported GABMs including binding (n = 995), packing (n = 590), using an STP device (n = 351), and tucking (n = 265). Each GABM had a distinct side effect profile. Pain (2.0%–48.2% past-year prevalence) and dermatologic concerns (0.5%–23.2% past-year prevalence) were reported across GABMs.
Conclusion:
While GABMs promote mental health and patient safety, they carry a risk of adverse physical health effects. Providers play a vital role in managing GABM-associated side effects to ensure patients can continue to affirm their gender identities.
Introduction
Approximately 1.3% and 0.4% of the U.S. adult population identify as transgender 1 and nonbinary, 2 respectively, with limited data about other gender minority identities. Adopting ways to affirm one’s gender identity improves wellness and mental health while facilitating gender euphoria. 3 In addition, gender affirmation is critical to offsetting the negative impacts associated with transphobia, cisheterosexism, discrimination, and social othering.4–6 For example, access to gender-affirming hormones in adolescence resulted in lower odds in adulthood of past-month suicidal ideation and severe psychological distress. 7
Nonhormonal, nonsurgical gender-affirming body modifications (GABMs)—binding, packing, using stand-to-pee (STP) devices, and tucking (Table 1)—can be important gender expression tools. 5 Extant literature focuses on the physical side effects of binding and tucking with limited data on other GABMs. More than 97% of participants endorsing binding experienced a negative health outcome at some point during their binding practice (e.g., pain, skin issues, shortness of breath). 8 Despite the high lifetime side effect prevalence, there were low rates (14.8%) of seeking health care for binding among these individuals. 9 Tucking may impair sperm concentration and motility, 10 and in a study of 79 transfeminine adults, 50% reported concern about the health effects of tucking, including itching, rash, and testicular pain. 11 There are few reports about side effects associated with packing and using STP devices.
Definitions of Nonhormonal, Nonsurgical Gender-Affirming Body Modifications
GABMs are daily or near-daily practices for a substantial proportion of gender minority individuals. A recent study suggested that greater than 60% of transgender and gender diverse adolescents assigned female at birth reported binding, suggesting high rates of utilization for gender affirmation. 12 GABM-attributed health effects should be taken in the context of the positive, protective impact that GABMs have on patient wellness.5,8,11 In this study, we examined the self-reported side effects of binding, packing, using STP devices, and tucking to corroborate previous work on binding and tucking and contribute to the understanding of other GABMs. We will briefly highlight the health care-seeking behaviors of participants who use GABMs to facilitate informed patient decision making on the use of GABMs.
Methods
Study population
Participants were enrolled in The Population Research in Identity and Disparities for Equality (PRIDE) Study, a national, longitudinal, cohort study of sexual and gender minority (SGM) adults in the United States. Participants were recruited through a variety of means, including newsletters, blog posts, advertisements, in-person outreach/events, and social media advertising. PRIDEnet, a network of dedicated individuals and SGM-serving organizations, was founded concurrently to ensure SGM communities were actively involved in all The PRIDE Study activities. The PRIDE Study 13 and PRIDEnet 14 have been previously detailed elsewhere. All participants provided informed consent. This study was approved by Stanford University, University of California, San Francisco, and WIRB-Copernicus Group’s Institutional Review Boards, as well as The PRIDE Study Research Advisory Committee and The PRIDE Study’s Participant Advisory Committee.
Measures and analysis
Those included in this analysis completed The PRIDE Study 2023 Annual Questionnaire (May 2023–May 2024). Participants were first asked to report having used binding, packing, STP devices, and tucking in the past 12 months by responding to the following yes/no questions: (1) In the PAST 12 MONTHS, have you used “binding”? (Binding refers to flattening your chest using materials such as bandages, cloth strips, and layering of shirts); (2) In the PAST 12 MONTHS, have you used “packing”? (Packing refers to placing an object in one’s underwear to resemble the appearance of a penis/phallus); (3) In the PAST 12 MONTHS, have you used “stand-to-pee” or STP device to stand up to pee? and (4) In the PAST 12 MONTHS, have you used “tucking”? (Tucking refers to concealing one’s genitals by placing them between and behind one’s legs and/or by pushing them inside your groin/abdomen) Those who answered affirmatively were presented with specific lists of adverse effects thought to be associated with specific GABMs. Participants selected or wrote in which health problems, if any, they experienced in the past 12 months that they believed to be caused by the specific GABM.
We collected participants’ self-reported gender identities, sexual orientations, and ethnoracial identities, all of which permitted multiple selections. Participants also self-classified into the most salient gender identity group. To describe the sample, we also collected age, sex assigned at birth, income, geographic region, and, for gender minority participants, transgender-related health care access. A comprehensive listing of all measures used is in Supplementary Appendix SA1. Finally, we used descriptive statistics to report GABM use, side effects, and participant sociodemographic information.
Results
The sample included 6296 participants who completed the 2023 Annual Questionnaire. The median age was 37.0 years (interquartile range: 29.1–53.4), and 65.7% were assigned female at birth. The most reported gender identities were nonbinary (25.7%) and cisgender women (24.5%); the most reported sexual orientations were queer (44.2%) and gay (32.5%). Approximately 53.7% reported annual incomes of ≤$50,000. More than 91% identified as White (alone or in combination with another ethnoracial identity), 6.3% reported being Hispanic/Latinx, and 10.8% reported more than one ethnoracial identity. Of all participants, 1694 (26.9%) endorsed any GABM. Among GABM users, the most common gender identities were nonbinary (49.7%), transgender man (34.4%), and genderqueer (29.5%); the most reported sexual orientations were queer (59.1%) and bisexual (34.2%); and 66.4% had incomes ≤$50,000.
Among GABM users, 995 (58.7%) participants reported binding, 590 (34.8%) reported packing, 351 (20.7%) reported using an STP device, and 265 (15.6%) reported tucking. The most common gender identities of those reporting binding were nonbinary, genderqueer, and transgender men. Among those reporting packing, they were transgender men, nonbinary, and men. Transgender men, nonbinary, and men were the most common gender identities of those using STP devices. With respect to tucking, transgender women, women, and nonbinary were the most represented gender identities. Participants’ self-classification of their gender identities into a single best category and additional demographic information are presented in Table 2.
Demographics of Users of Nonhormonal, Nonsurgical Gender-Affirming Body Modifications in The Population Research in Identity and Disparities for Equality Study
Among the 6296 participants, 46.5% selected more than one gender identity; 45.8% selected more than one sexual orientation; and 10.8% selected more than one ethnoracial identity.
Participants were asked, “What is your current gender identity? (Check all that apply).”
Participants could select more than one answer choice. As such, these numbers may sum to more than 100%.
Participants were asked, “If you had to choose only one of the following terms, which best describes your current gender identity? (‘Cisgender’ here means identifying with the sex assigned to you at birth. For example, a cisgender woman identifies as a woman and was assigned female sex at birth).”
Participants were asked, “What is your current sexual orientation? (Check all that apply).”
Participants were asked, “What was the sex assigned to you at birth, for example, on your original birth certificate?”
Participants were asked, “Which categories describe you? (Check all that apply).”
Participants were asked, “What were your individual earnings (in U.S. dollars) before taxes and deductions from all sources in the 2022 tax year?”
Participants were asked, “What is your ZIP code? (This is the 5-digit code that helps direct U.S. Mail to you).” ZIP code was mapped to state, which was subsequently mapped to U.S. census region.
Participants were asked, “In the PAST 12 MONTHS, have you gone to a doctor, health care provider, or clinic for transgender-related health care (such as hormone treatment)?” This question was only given to gender minority participants (n = 2967). Therefore, the number of responses in each column may sum to a smaller number than the sums for the other variables.
GABM, gender-affirming body modifications; IQR, interquartile range; STP, stand-to-pee. All percentages are calculated as column percentages.
Adverse effects attributed to GABMs in the past year were reported by 66.6% of participants who bind, followed by tucking (43.4%), packing (12.5%), and using STP devices (9.4%). For binding, pain was the most frequent adverse effect reported and was experienced by slightly less than half (480, 48.2%). Other adverse effects reported included breast tenderness (237, 23.8%), skin changes (231, 23.2%), bad posture (202, 20.3%), respiratory issues (182, 18.3%), and feeling lightheaded or dizzy (142, 14.3%). For tucking, the most common side effects were itching (46, 17.4%), testicular pain (46, 17.4%), and skin rashes (39, 14.7%). For packing, the most common side effect was skin rash (41, 6.9%), followed by pain/numbness in the groin area (23, 3.9%), and urinary tract or bladder infections (18, 3.1%). Among those using STP devices, the most common side effects were dermatologic with nine (2.6%) participants reporting rash and five (1.4%) reporting other skin changes. All self-reported health problems are described in Table 3. Finally, 60.5% of gender minority participants reporting GABMs noted they had gone to a doctor, other health care provider, or clinic for transgender-related health care in the past 12 months.
Self-Reported Side Effects Among Users of Nonhormonal, Nonsurgical Gender-Affirming Body Modifications in The Population Research in Identity and Disparities for Equality Study
Participants who reported binding in the past 12 months were asked, “Please indicate below which of the following health problems you have had in the PAST 12 MONTHS, and you believe that they were caused by binding. (Check all that apply).”
Participants who reported packing in the past 12 months were asked, “Please indicate below which of the following health problems you have had in the PAST 12 MONTHS, and you believe that they were caused by packing. (Check all that apply).”
Participants who reported using a stand-to-pee device in the past 12 months were asked, “Please indicate below which of the following health problems you have had in the PAST 12 MONTHS, and you believe that they were caused by using a “stand-to-pee” (STP) device. (Check all that apply).”
Participants who reported tucking in the past 12 months were asked, “Please indicate below which of the following health problems you have had in the PAST 12 MONTHS, and you believe that they were caused by tucking. (Check all that apply).”
Discussion
The study of GABMs is underrepresented in the literature. To our knowledge, this is the first study focusing on multiple GABMs and describing the sociodemographics of and side effects experienced by those using them. Our finding that over 66% of those using GABMs reported ≤$50,000 in annual income is notable, especially in the setting of the documented access-to-care issues experienced by LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other SGM identities) individuals.15–17 Gender-affirming health care is being increasingly restricted across the United States. GABMs may constitute one of the remaining options for individuals to affirm their gender identity through appearance alteration. 18 Financial barriers to care may be burdensome for patients endorsing GABMs; some patients may use GABMs while waiting to access other gender-affirming procedures. For example, someone who desires top surgery (breast reduction/removal) but is uninsured or cannot afford the surgery may bind until they are financially able to undergo surgery. That said, some gender diverse individuals may not desire gender-affirming surgeries and may prefer using GABMs indefinitely.
Participants reported health problems associated with each GABM. Binding and tucking were most likely to be associated with side effects with 66.6% and 43.4% of participants, respectively, reporting at least one adverse effect in the past 12 months. Packing and using STP devices have comparably rarer side effect profiles, likely because they cause less physical restriction than binding and tucking. Nevertheless, packing and STP devices were associated with self-reported negative health outcomes and should be assessed by clinicians for side effects.
A meaningful number of participants—1 in 3 people who bind, roughly 9 in 10 people who pack or use STP devices, and nearly 1 in 2 people who tuck—successfully used their GABM of choice with no negative side effects in the past 12 months. More research is needed to understand what practices support symptom risk reduction so that gender minority individuals have the option to use GABMs without experiencing side effects.
Pain was a frequent concern reported across GABMs, consistent with previous studies on binding and tucking.8,11 The nature of binding and tucking, respectively, is to compress breasts to make them less obvious and to hide penis, testicles, and scrotum to decrease the appearance of male external genitals under clothes. These physical actions can result in pain. Therefore, an important role for clinicians is ensuring that patients can continue GABMs comfortably. GABM-associated pain may be due to incorrect use—for example, using a too tightly fitting binder—which could be mitigated or prevented with nonjudgmental patient counseling. Providers should seek out education to be able to initiate conversations with their patients about reducing harm and maximizing benefit from GABMs. 19 Our analysis revealed that approximately 60.5% of gender minority individuals using GABMs sought out transgender-related health care in the past 12 months, indicating substantial opportunities for engaging these patients in supportive counseling around GABM use.
Dermatologic concerns (rashes, skin infections, skin changes, itching, etc.) were commonly reported among people using GABMs, suggesting that dermatologists may have an important role to play in caring for them. This suggestion should be contextualized within a growing understanding among dermatologists of the unique needs of LGBTQIA+ individuals, particularly patients on gender-affirming hormone therapy. Gender minority patients may seek facial, chest, or genital hair removal 20 ; hair removal was recently demonstrated to be associated with improved mental health outcomes in this population. 21 Other patients may seek out treatment for acne 22 and hair loss in the setting of using gender-affirming testosterone. 23 As LGBTQIA+ dermatology expands, dermatologists should gain familiarity with identifying and treating GABM side effects. As many LGBTQIA+ individuals using GABMs may initially present in the primary care setting, primary care providers (PCPs) must similarly identify these dermatologic complications. Further study is needed to qualify the specific dermatologic conditions associated with GABMs.
Looking forward, it would be beneficial to learn if side effects lead to delay or discontinuation of GABMs. These adverse outcomes constitute valuable opportunities for providers to work with patients to affirm their gender identity while optimizing their physical wellness. A 2018 study showed that more than 80% of participants reporting binding believed having a conversation about chest binding with their providers was important, but less than 15% of participants ultimately sought out binding-related health care. 9 These data suggest that GABM-reporting individuals desire to connect with health care providers about their gender-affirming practices but often do not do so. Our finding that 60.5% of gender minority participants reporting GABMs sought out transgender-related health care in the past 12 months indicates potential missed opportunities for patient- or provider-initiated conversations about GABMs in clinical encounters. GABMs may not be brought up by patients or providers during health care encounters for many reasons, including a lack of provider awareness of GABMs and a belief that GABMs are not medically relevant interventions. The role that providers can play in supporting patients using GABMs is unexplored and constitutes an intriguing research query. More importantly, our findings suggest that addressing GABMs in health care encounters could play a role in expanding the scope of gender-affirming care.
Finally, evidence already exists for the mental health benefits of gender-affirming surgery and hormone therapy. 4 Recent research demonstrated that daily binding was employed to achieve psychological comfort and mitigate chest dysphoria in gender diverse individuals designated female at birth. 24 Further study is warranted to ascertain if other GABMs play similar roles and if GABM use is protective against specific mental health conditions (e.g., depression, anxiety).
Strengths and limitations
One strength of our study is that we simultaneously examined the demographic data and side effect profiles of multiple GABMs, whereas prior research has focused on individual GABMs. Furthermore, The PRIDE Study includes participants from all geographic regions of the United States, representing a broad array of diverse LGBTQIA+ identities, income brackets, and educational levels. In addition, assessing GABM usage in the past 12 months (compared to lifetime use) allows for simpler, less confounded interpretation of side effects. Most participants identified as White, thereby limiting our ability to assess for differential side effects based on ethnoracial identity. While our study measured prevalence, it did not measure symptom severity, duration, or recurrence.
Conclusion
This study highlighted multiple GABMs used by individuals to affirm their gender identity. We have identified several under-examined adverse effects associated with GABMs, suggesting an important role for PCPs and specialists (e.g., dermatologists) in managing GABM-associated side effects. These findings may be helpful in generating data-driven resources, such as educational materials or decision aids, for patients and providers to refer to when discussing GABMs in clinical contexts. Finally, because many individuals using GABMs reported low incomes, socioeconomic disparities (e.g., inequitable access to care) may play a role in the health experiences of GABM users.
Footnotes
Acknowledgments
The PRIDE Study is a community-engaged research project that serves and is made possible by LGBTQIA+ community involvement at multiple points in the research process, including the dissemination of findings. We acknowledge the courage and dedication of The PRIDE Study participants for sharing their stories; the careful attention of PRIDEnet’s Participant Advisory Committee members for reviewing and improving every study application; and the enthusiastic engagement of PRIDEnet Ambassadors and Community Partners for bringing thoughtful perspectives as well as promoting enrollment and disseminating findings. For more information, please visit 
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Authors’ Contributions
B.L.S.: Conceptualization, investigation, and writing—original draft preparation. N.K.T.: Data curation, formal analysis, methodology, validation, and writing—review and editing. J.A.M.: Data curation, formal analysis, and writing—review and editing. S.M.P.: Writing—review and editing. T.C.P.: Writing—review and editing. M.E.L.: Investigation, methodology, and writing—review and editing. A.F.: Investigation, methodology, and writing—review and editing. J.O.-M.: Funding acquisition, investigation, methodology, project administration, resources, and writing—review and editing. M.R.L.: Conceptualization, data curation, funding acquisition, investigation, methodology, project administration, resources, supervision, and writing—review and editing.
Disclaimers
The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or its Methodology Committee. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; and decision to submit the article for publication.
Author Disclosure Statement
J.O.-M. has received consultation fees from Ibis Reproductive Health, Hims and Hers Health Inc., Folx Health Inc., Sage Therapeutics, and Upstream Inc. on topics unrelated to this work. M.R.L. received consultation fees from Hims and Hers Health Inc., Folx Health Inc., Otsuka Pharmaceutical Development and Commercialization, Inc., and the American Dental Association on topics unrelated to this work.
Funding Information
Research reported in this article was partially funded through a PCORI Award (award number PPRN-1501–26848) to M.R.L.