Better mental health in transgender people who started taking hormones as teenagers

For transgender people, starting gender-affirming hormone therapy in adolescence is linked to better mental health than waiting until adulthood, according to new research from the Stanford University School of Medicine.

The study, which was published online on January 12, 2022, in PLOS ONE, drew on data from the largest-ever survey of American transgender adults, a group of more than 27,000 people who responded in 2015. The new study found that transgender people who started treatment hormones in adolescence had fewer suicidal thoughts, were less likely to suffer from major mental disorders, and had fewer substance abuse problems than those who started using hormones as adults. The study also documented better mental health in those who received hormones at any age than those who wished but never received the treatment.

Gender-affirming hormone therapy with estrogen or testosterone can help align a transgender person’s physical characteristics with their gender identity. In adolescence, hormone therapy can allow a transgender teenager to navigate puberty in a way that matches their gender identity.

“This study is especially relevant now because many state legislatures are introducing bills that would ban this type of care for transgender youth,” said Jack Turban, MD, postdoctoral fellow in pediatric and adolescent psychiatry at Stanford Medicine. “We are adding to the evidence base that shows why gender-affirming care is beneficial from a mental health perspective.”

Turban is the lead author of the study. The lead author is Alex Keuroghlian, MD, associate professor of psychiatry at Harvard Medical School and director of the National LGBTQIA+ Health Education Center at the Fenway Institute.

The largest survey of transgender adults

Researchers analyzed data from the 2015 US Transgender Survey, which includes survey responses from 27,715 transgender people nationwide. The participants, who were at least 18 years old when they were interviewed, completed detailed questionnaires about their lives.

Because some transgender people don’t want hormone treatment, the study focused on 21,598 participants who said they wanted to receive hormones. Results were analyzed by when participants started hormone therapy: 119 started at ages 14 or 15 (early adolescence), 362 started at ages 16 or 17 (late adolescence), 12,257 started after their 18th birthday (adulthood) and 8,860 participants, who served as a control group, wanted but never received hormone therapy.

Participants answered several questions about their mental health, including their history of suicidal thoughts and suicide attempts, as well as their history of excessive alcohol and illicit drug use. They completed a questionnaire to assess whether they had experienced severe psychological distress, meaning they met the criteria for a diagnosable mental illness, in the previous month.

The analysis controlled for several factors that could influence participants’ mental health regardless of whether or not they received hormone treatment: age at the time of the survey; gender identity; sex assigned at birth; sexual orientation; race or ethnic origin; level of family support for gender identity; Relationship status; level of education; employment status; household income; use of puberty suppression treatment; any attempt to force them to be cisgender; and the experience of any verbal, physical, or sexual harassment based on their gender identity in grades K-12.

Compared to members of the control group, participants who took hormone therapy were less likely to experience severe psychological distress in the past month and less likely to have suicidal ideation in the past year. The risks of severe psychological distress were reduced by 222%, 153% and 81% for those who started the hormones in early adolescence, late adolescence and adulthood, respectively. The risk of suicidal ideation in the previous year was 135% lower in people who started hormones in early adolescence, 62% in those who started in late adolescence, and 21% in those who started in adulthood, compared to the control group.

Additionally, participants who started hormones in their early or late teens had lower odds of binge drinking in the previous month and lifetime illicit drug use than those who started. started hormones in adulthood.

But the researchers found that those who started hormone treatment as adults were more likely to engage in excessive alcohol and illicit substance use than those who never had access to treatment. “Some people may become more confident and socially engaged when they start taking hormones,” Turban said, adding that in some cases this increased confidence and social engagement may be linked to substance use. “This finding speaks to the importance of creating culturally appropriate substance abuse counseling programs for transgender people.”

To find out if participants’ pre-treatment mental health influenced their ability to access treatment, researchers also assessed whether participants in each group had ever been suicidal but had not had suicidal feelings in the previous year. .

“It was a measure of improvement in mental health over time,” Turban said. “People were more likely to meet these criteria if they accessed and took hormones than if they did not.” The finding implies that access to hormones improves mental health rather than the reverse, he said.

Building evidence for gender-affirming medical care

Turban and his colleagues hope lawmakers across the country will use the new findings to inform their policy decisions. Although several bills banning gender-affirming medical care for transgender youth have been introduced in state legislatures in recent years, nearly all of them failed to become law, he said, adding that all major medical organizations support the provision of gender-affirming medical care, including hormone therapy for patients who desire it and who meet the criteria established by the Endocrine Society and the World Professional Association for Transgender Health.

“There’s no one right way to be transgender,” Turban said. Some transgender people don’t want to take hormones and are comfortable with their body as it is. Young people who seek care at gender clinics routinely receive counseling as part of their treatment to help them determine what types of care are best suited to their situation.

For those who desire gender-affirming hormones, being denied access to treatment can cause significant distress, Turban said.

“For some young transgender people, their negative reactions to living in bodies that develop during puberty in a way that doesn’t match who they know themselves can be very damaging,” he said. For example, people who feel uncomfortable growing breasts may react by binding their breasts so tightly that they develop skin infections or rib fractures.

“These results will come as no surprise to providers, but unfortunately many lawmakers have never met transgender youth,” Turban said. “It’s important that lawmakers see the numbers that support the experiences of transgender youth, their families, and people who work in this field.”

Reference: “Access to gender-affirming hormones during adolescence and mental health outcomes in transgender adults” by Jack L. Turban, Dana King, Julia Kobe, Sari L. Reisner, and Alex S. Keuroghlian, 12 January 2022, PLOS ONE.
DOI: 10.1371/journal.pone.0261039

Researchers from the Fenway Institute, Brigham and Women’s Hospital, Harvard Medical School and Harvard TH Chan School of Public Health contributed to the study.

The research was funded by the American Academy of Child & Adolescent Psychiatry (supported by industry sponsors Arbor and Pfizer), Harvey L. and Maud C. Sorensen Foundation, National Institute of Mental Health (grant MH094612) and the Health Resources and Services Administration (grant U30CS22742).

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