This is an English summary of the following original study on gender-affirming treatment:
Chen, D., Berona, J., Chan, Y. M., Ehrensaft, D., Garofalo, R., Hidalgo, M. A., Rosenthal, S. M., Tishelman, A. C., and Olson-Kennedy, J. (2023). “Psychosocial Functioning in Transgender Youth after 2 Years of Hormones”. New England Journal of Medicine, 388: 240– 250. https://www.nejm.org/doi/full/10.1056/NEJMoa2206297
What Was the Aim of This Study?
The aim of this study was to assess the effects of gender-affirming hormone treatment on the mental health and social well-being of transgender youth over a period of two years.
Why Was This Study Needed?
Transgender youth are a vulnerable population at risk of suffering from mental health problems and social challenges. The available research to date indicates that mental health and social well-being improve with access to gender-affirming healthcare. However, withholding healthcare can worsen these problems.
Despite this, some parts of Europe and the United States are restricting access to gender-affirming healthcare for transgender youth. This is largely due to political reasons. It also reflects controversies about the quality of evidence for the use of gender-affirming hormones in young people. Therefore, research that specifically examines the effects of gender-affirming hormone treatment on the mental health and social well-being of transgender youth is needed to inform the debate.
What Did This Study Do?
This study was a prospective cohort study. This is a kind of study which follows up a group of participants over a period of time and assesses them for a particular outcome.
The participants in this study were 315 transgender people aged between 12 and 20. These included 190 transmasculine people, 106 transfeminine people, and 19 nonbinary people, who were patients at four gender clinics in the United States. The participants commenced gender-affirming hormone treatment at the beginning of the study and were followed up for 2 years.
Researchers assessed the mental health and social well-being of the participants at baseline before commencing gender-affirming hormone treatment. They then reassessed the mental health and social well-being of the participants 6, 12, 18, and 24 months after commencing gender-affirming hormone treatment. The outcomes that were measured include appearance congruence (how much one’s appearance is perceived to align with one’s gender), depression, anxiety, positive affect (pleasant feelings), and life satisfaction.
What Were the Findings?
General findings:
- After 24 months of gender-affirming hormone treatment, participants reported significant improvements in mental health and social well-being.
- These improvements were found across all of the measured outcomes. Appearance congruence, positive affect, and life satisfaction increased significantly, while depression and anxiety decreased significantly.
Mental health:
- The mean depression score in the study population was in the mild range at baseline. It decreased to a clinically insignificant level after 24 months of gender-affirming hormone treatment.
- In the 27 participants who had depression scores in the severe range at baseline, the depression scores decreased to minimal and moderate ranges in 67% of cases.
- In the 47 participants who had anxiety scores in the clinically significant range at baseline, the anxiety scores decreased to clinically insignificant levels in 38.5% of cases.
- Participants from ethnic minority groups and participants who were assigned male at birth had higher depression scores at baseline and reported smaller decreases in their depression scores after treatment. This indicates that mental health in transgender youth is influenced by other social factors, such as inequalities concerning ethnicity and gender.
Appearance congruence:
- Appearance congruence was shown to be an important factor that influences the other outcomes.
- Participants who were more satisfied with their appearances at baseline had lower depression scores at baseline. Improvements in appearance congruence with treatment were associated with decreases in depression scores.
- This suggests that increasing appearance congruence is an important aim of gender-affirming hormone treatment.
Pubertal stage:
- Participants who commenced gender-affirming hormone treatment earlier in puberty reported better mental health and social well-being at baseline than participants who commenced treatment later in puberty.
- This suggests that commencing gender-affirming hormone treatment earlier in puberty is preferable. It avoids the gender incongruent bodily changes associated with puberty.
Adverse events:
- Two participants died from suicide during the study period.
- Suicide is understood to be a complex outcome of multiple factors, which can include gender dysphoria. However, there may have been other possible influences that were not reported. For example, the extent of mental health care provided throughout the study.
- There is NO evidence that the deaths were related to the treatment.
Were There Any Limitations?
The biggest limitation is that the study did not have a control group. Hence, it was not possible to compare outcomes in transgender youth who received gender-affirming hormone treatment with outcomes in transgender youth who did not receive treatment. However, previous research has shown that withholding gender-affirming healthcare is associated with poorer outcomes for mental health and social well-being (Tan et al., 2022). Viewed in this wider context, this current study provides evidence that mental health and social well-being in transgender youth improve with two years of gender-affirming hormone treatment.
Another limitation is the length of the follow-up. Given that gender-affirming hormone treatment can take up to five years to reach its maximum effect, future research will need a follow-up period of more than two years to understand the long-term effects on mental health and social well-being more thoroughly.
While this study measured appearance congruence, depression, anxiety, positive affect, and life satisfaction, it did not measure other factors that influence mental health and social well-being in transgender people. These include the quality of peer relations and family support. Including these factors in future research could improve the understanding of how different factors interact with gender-affirming hormone treatment to influence mental health and social well-being in transgender youth.
What Are the Implications of This Study?
This study provides evidence that gender-affirming hormone treatment improves mental health and social well-being in transgender youth. This is consistent with previous research which shows that gender-affirming hormone treatment has psychological benefits in transgender youth (Allen et al., 2019; de Vries et al., 2014; Kuper et al., 2016) and in transgender adults (Baker et al. 2021; Colizzi et al., 2014; Fisher et al., 2016).
Furthermore, this study provides evidence that some of the benefits of gender-affirming hormone treatment are related to its positive effects on appearance congruence. This suggests that commencing gender-affirming hormone treatment earlier in puberty is preferable to avoid the gender incongruent bodily changes associated with puberty.
In light of the above evidence of the benefits of gender-affirming hormone treatment and the harms of withholding treatment, this study supports the use of gender-affirming hormone treatment in transgender youth with gender dysphoria.
References
- Allen, L. R., Watson, L. B., Egan, A. M., and Moser, C. N. (2019). “Well-Being and Suicidality Among Transgender Youth After Gender-Affirming Hormones”. Clinical Practice in Pediatric Psychology, 7: 302–311.
- Baker, K. E., Wilson, L. M., Sharma, R., Dukhanin, V., McArthur, K., and Robinson, K. A. (2021). “Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. Journal of the Endocrine Society, 5 (4): bvab011.
- Chen, D., Berona, J., Chan, Y. M., Ehrensaft, D., Garofalo, R., Hidalgo, M. A., Rosenthal, S. M., Tishelman, A. C., and Olson-Kennedy, J. (2023). “Psychosocial Functioning in Transgender Youth after 2 Years of Hormones”. New England Journal of Medicine, 388: 240–250.
- Colizzi, M., Costa, R., and Todarello, O. (2014). “Transsexual Patients’ Psychiatric Comorbidity and Positive Effect of Cross-Sex Hormonal Treatment on Mental Health: Results from a Longitudinal Study”. Psychoneuroendocrinology, 39: 65–73.
- de Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A., and Cohen-Kettenis, P. T. (2014). “Young Adult Psychological Outcome after Puberty Suppression and Gender Reassignment”. Pediatrics, 134: 696–704.
- Fisher, A. D., Castellini, G., Ristori, J., Casale, H., Cassioli, E., Sensi, C., Fanni, E., Amato, A. M., Bettini, E., Mosconi, M., Dèttore, D., Ricca, V., and Maggi, M. (2016). “Cross-Sex Hormone Treatment and Psychobiological Changes in Transsexual Persons: Two-Year Follow-Up Data”. Journal of Clinical Endocrinology and Metabolism, 101 (11): 4260–4269.
- Kuper, L. E., Stewart, S., Preston, S., Lau, M., and Lopez, X. (2020). “Body Dissatisfaction and Mental Health Outcomes of Youth on Gender Affirming Hormone Therapy”. Pediatrics, 145 (4): e20193006.
- Tan, K. K. H., Byrne, J. L., Treharne G. J., and Veale, J. F. (2022). “Unmet Need for Gender-Affirming Care as a Social Determinant of Mental Health Inequities for Transgender Youth in Aotearoa/New Zealand”. Journal of Public Health, fdac131.