Gender-Affirming Hormone Therapy Linked to Better MH in Trans Youth

Adolescents and young adults who are transgender or gender nonbinary face several hurdles in finding, accessing, and receiving gender-affirming hormone therapy. Physicians and other health care professionals who are trained in providing gender-affirming care are in short supply, patients may encounter stigma from health professionals who are not well versed in the medical and mental health needs of transgender and nonbinary people, and financing and transportation present logistical challenges to accessing care. Furthermore, these patients may live in a state that has proposed legislation to restrict or outlaw gender-affirming hormone therapy.

Yet evidence is mounting that receiving gender-affirming hormone therapy in youth is associated with better mental health outcomes in patients who wish to receive it. A study published in the April issue of the Journal of Adolescent Health found a link between gender-affirming hormone therapy and lower rates of depression and suicidality among transgender and nonbinary youth who received it when they wanted it, compared with those who wanted it but did not receive it.

The Trevor Project

Amy E. Green, Ph.D., vice president of research at The Trevor Project in West Hollywood, and colleagues analyzed data from 11,914 transgender or nonbinary youth aged 13 to 24 years who participated in a 2020 survey of 34,759 lesbian, gay, bisexual, transgender, queer, and questioning people. Half of the transgender and nonbinary youth reported that they were not using gender-affirming hormone therapy but would like to receive it, 36% reported that they were not interested in receiving it, and 14% said they were receiving it. Participants who lived in the South, where several states have proposed banning gender-affirming hormone therapy, had the lowest rates of access to it. Participants of color reported lower rates of access to the therapy compared with White participants.

“The large gap in access to desired care, particularly among transgender and nonbinary youth of color, points to the need for expanded access to services that understand and support transgender and nonbinary youth,” Green told Psychiatric News.

Participants who received gender-affirming hormone therapy were 27% less likely to have symptoms of depression as measured by the Patient Health Questionnaire-2 and 26% less likely to report seriously considering suicide than those who desired the therapy but did not receive it. In an analysis of participants under 18 years old, those who received gender-affirming hormone therapy were also 39% less likely to report recent depression and 38% less likely to have a past-year suicide attempt than their peers who wanted the therapy but did not receive it.

“These data are part of a larger body of research pointing to a significant relationship between access to gender-affirming care and better mental health outcomes among transgender and nonbinary youth,” Green said. “Health care professionals, including mental health professionals, should seek out continuing education opportunities to increase their cultural competence in working with transgender and nonbinary populations.”

Stanford Children’s Health

Jack L. Turban, M.D., a psychiatrist and chief fellow in child and adolescent psychiatry at Stanford University School of Medicine, agrees. He is the lead author of a study published in January in PLOS One that found that transgender people who received gender-affirming hormone therapy during early or late adolescence were less likely to have past-month suicidal ideation and past-month severe psychological distress in adulthood compared with those who desired the therapy in adolescence but did not receive it.

“Unfortunately, there are too few physicians trained in providing gender-affirming care to transgender and gender diverse youth. This means that clinics often have long waitlists, sometimes over a year long. Many families travel over 100 miles to receive care,” Turban said. “It is vital that we implement more training initiatives in medical schools, residencies, and fellowships to build a workforce capable of providing competent and compassionate care.”

In their study, Turban and his colleagues analyzed data from 21,598 transgender adults in the 2015 U.S. Transgender Survey who reported ever desiring gender-affirming hormone therapy. They found that 41% of participants never received it, 0.6% received it in early adolescence when they were aged 14 to 15 years, 1.7% received it in late adolescence when they were aged 16 to 17 years, and 56.8% received it in adulthood (aged 18 years and older).

Compared with participants who desired gender-affirming hormone therapy but never received it, those who received it in early adolescence, late adolescence, or adulthood had a 135%, 62%, and 21% decrease in odds of suicidal ideation, respectively. Furthermore, participants who received the therapy between the ages of 14 and 17 years had lower odds of past-month severe psychological distress, past-month binge drinking, and lifetime illicit substance use compared with those who received it in adulthood.

Mary Ann Liebert, Inc., publishers

William Byne, M.D., Ph.D., a professor of clinical psychiatry in the Division of Gender, Sexuality, and Health at Columbia University College of Physicians and Surgeons in New York, said that these two studies add to the literature supporting gender-affirming care in transgender youth.

“These survey analyses may be particularly helpful for mental health professionals with little experience working with gender diverse patients in understanding the range of experiences across the population,” said Byne, who was not involved in either study. “Medical and mental health professionals, however, treat individual patients, not populations, and therefore must work within a model of patient-centered care that entails carefully assessing and appropriately addressing the particular needs of each individual patient.”

Byne noted the challenges of aligning care should physicians worry that their patients may later regret the treatment.

“[These physicians] may insist on a prolonged or interminable period of assessment, often with a mental health professional, that does not address the youth’s gender-affirming needs and associated dysphoria,” Byne explained. “As a result, the youth may become increasingly frustrated, dysphoric, and emotionally dysregulated, all of which may be interpreted as psychological instability that must be adequately controlled before affirming their experienced gender or initiating hormonal treatment.”

Byne added that psychiatrists should have resources at hand to make appropriate referrals.

“Psychiatrists who are not experienced in gender-affirming care need to know when, where, and to whom to refer youth and their parents or caregivers for appropriate gender-focused care and support that ameliorates rather than exacerbates anxiety and dysphoria,” he said.

A Call to Action

The experts agree that these data illuminate a need to ensure that transgender youth receive gender-affirming care, including gender-affirming hormone therapy, if they desire it.

“Legislation should not prohibit gender-affirming care or penalize professionals who provide it,” said Byne.

Green emphasized the importance of advocacy.

“From a social justice perspective, these data should serve as a call to action to stand up for laws and policies that increase access to gender-affirming care and to stand against the wave of anti-transgender health care bans we are seeing introduced in states across the U.S.,” she said.

Turban noted that all major medical associations, including APA, oppose legislation that would outlaw gender-affirming care for transgender youth, but added a caveat.

“Unfortunately, physicians have historically not been very involved in state legislative processes,” Turban said. “I am hopeful that psychiatrists will contact their state legislatures to educate them about the mental health needs of transgender youth, share relevant peer-reviewed research, and encourage them to implement evidence-based public policies that will best promote the mental health of young people.”

Green and colleagues reported no outside funding for their study. The study by Turban and colleagues reported funding from the American Academy of Child & Adolescent Psychiatry (as supported by Arbor Pharmaceuticals LLC and Pfizer), the National Institute of Mental Health, The Sorensen Foundation, and the Health Resources and Services Administration Bureau of Primary Health Care. ■