• Posted January 19, 2023

Hormonal Therapies Are Boosting the Mental Health of Trans Youth

As numerous U.S. states move to restrict transgender health care, a new study shows that such care can substantially improve teenagers' mental health.

The study, published in the New England Journal of Medicine, followed transgender and nonbinary teenagers who received "gender-affirming" hormones -- either estrogen or testosterone -- for two years.

During that time, researchers found, two-thirds of teens who'd had moderate to severe depression showed a marked improvement. Many also saw their anxiety symptoms wane and reported gains in their satisfaction with life.

Experts who were not involved in the study said it bolsters evidence of the benefits of gender-affirming care -- health care services for transgender and nonbinary people.

That care can include "puberty blockers" -- medications that put a pause on pubertal development -- and gender-affirming hormones, which alter patients' physical traits to better align with their gender identity.

In the study, there was a direct correlation between teenagers' mental health gains and the degree to which hormone therapy had given them their desired physical appearance.

It's known that compared with their peers, transgender and nonbinary teenagers are at higher risk of mental health issues, substance use and suicide.

A survey last year by the nonprofit Trevor Project found that between 12% and 22% of transgender and nonbinary young people had attempted suicide in the past year. And few -- one-third -- felt they were accepted at home.

Based on a number of small studies, it appears gender-affirming care often helps.

"Gender-affirmative care is safe, effective and even lifesaving," said Dr. Michelle Forcier, a professor of pediatrics at Brown University. "The medications used can lead to more positive mental and physical health outcomes for the vast majority of people accessing this care."

The new study -- larger and longer-term than past ones -- reinforces that, according to Forcier.

The findings are based on 315 transgender or nonbinary patients, ages 12 to 20, who had gender-affirming care at one of four U.S. academic medical centers. Some were prescribed puberty blockers during early puberty, and all started on gender-affirming hormones: either estrogen to encourage feminine traits like breast development and reduced muscle mass and body hair; or testosterone to foster traits like increased muscle, a deeper voice and facial hair.

Researchers led by Diane Chen, of Lurie Children's Hospital of Chicago, followed the patients for two years.

On average, they found, study participants saw improvements in depression and anxiety symptoms, and a boost in life satisfaction.

Of 27 who'd had severe depression before hormone therapy, 67% had improved to the "minimal or moderate" depression range after two years. Meanwhile, of 47 young people who'd had an anxiety disorder, nearly 39% no longer met that diagnosis after two years.

Dr. Gina Sequeira, co-director of Seattle Children's Gender Clinic, said the study was rigorously done and supports the benefits of early access to gender-affirming care.

She also pointed to some of the common myths about such care.

One is that gender-affirming care is some sort of fringe experiment. It is, in fact, recommended by major medical organizations, including the American Academy of Pediatrics, Sequeira stressed.

Beyond that, she said, no medications are given before a child starts puberty, and when a patient is younger than 18, parental consent is required for any medication.

The findings come at a time when gender-affirming care is under threat in many U.S. states. Legislators are considering bills that would ban minors -- and even young adults in some cases -- from accessing such care.

"Legislators are interfering with parents' right to make decisions in the best interests of their child," Sequeira said.

Forcier agreed, saying "children should not be pawns of politicians."

She added: "A decision to start and engage in gender-affirmative care should be personal and private -- between the child, the caregivers and the health care providers involved."

Hormones alone are not a panacea, however. In this study, depression and anxiety persisted in some kids, and two died by suicide over the two-year follow-up.

In addition, the mental health benefits were mainly seen among transmasculine young people (those designated female at birth who identified as male).

One reason, both doctors said, could be because it takes several years for estrogen to spur changes in physical traits like breast development. Plus, estrogen does not erase the masculine traits that come with the testosterone surge of puberty.

But there's also the social factor, Forcier pointed out: Transfeminine people may face even more discrimination, and have less support, than transmasculine people do.

That points to something bigger, both doctors said: Like all kids, transgender and nonbinary teens need supportive adults and peers in their lives in order to thrive.

Societal messages matter, too, Forcier stressed. And the messages behind current legislation, she said, are "pretty scary, even horrifying" for kids and families seeking gender-affirming care.

More information

The U.S. Office of Population Affairs has more on gender-affirming care.

SOURCES: Michelle Forcier, MD, MPH, professor, pediatrics, Brown University Warren Alpert Medical School, Providence, R.I.; Gina Sequeira, MD, MS, co-director, Gender Clinic, Seattle Children's, Seattle; New England Journal of Medicine, Jan. 19, 2023