Transgender youths reported more life satisfaction and fewer symptoms of depression and anxiety after receiving gender-affirming hormone therapy for two years, according to a new study.
The research, published Wednesday in the New England Journal of Medicine, evaluated 315 transgender youths between 12 to 20 years old, with an average age of 16, over the course of two years while they were being treated with gender-affirming hormone therapy.
The researchers are a group of physicians and professors associated with universities and children’s hospitals in Chicago, Boston and Los Angeles. The study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
The researchers used scales that measured depression and anxiety, positive emotions and sense of life satisfaction, and appearance congruence — meaning how much a trans person feels their external appearance aligns with their gender identity. Participants rated each of these factors numerically.
Researchers found that, on average, participants reported increases in positive emotions, life satisfaction and appearance congruence. Those increases were associated with decreases in depression and anxiety symptoms.
The findings, researchers wrote, support the use of hormone therapy as an effective treatment for trans and nonbinary youths.
The researchers said their findings also suggest appearance congruence is important for trans and nonbinary youths’ well-being. The mental and physical health differences between youth who had undergone substantial “gender-incongruent” puberty — which is the puberty associated with their assigned sex at birth — and those who had not also supported the importance of appearance congruence for well-being.
Only a small subgroup (24 participants) in the study did not undergo extensive gender-incongruent puberty, either because they began puberty blockers at an early stage of puberty, or started gender-affirming hormones when their puberty began later.
“Those who had not gone through substantial gender-incongruent puberty had higher scores for appearance congruence, positive affect, and life satisfaction and lower scores for depression and anxiety at baseline than youth who had undergone substantial endogenous puberty,” meaning the puberty associated with their assigned sex, the researchers wrote.
They also noted that depression and anxiety symptoms decreased significantly and life satisfaction increased significantly among trans and nonbinary youth designated female at birth but not for those designated male at birth. This difference, they wrote, could be attributed to a few factors: First, some physical changes associated with estrogen, such as breast growth, can take between two to five years to reach their “maximum effect.”
As a result, the researchers speculated that a longer follow-up period may be necessary for trans feminine youth to see an effect on mental health.
Second, they wrote that physical changes that result from going through testosterone-driven puberty, such as a deeper voice, might be “more pronounced and observable” than those associated with an estrogen-driven puberty.
Third, the researchers wrote that it’s possible the differences in anxiety and life satisfaction could be related to less social acceptance of transfeminine people, compared with transmasculine people.
Research published in the Journal of Adolescent Health in 2021 suggested that transfeminine youth may experience more minority stress, which is stress faced by stigmatized minority groups like LGBTQ people, than transmasculine youth.
The authors of the new study wrote that understanding the effect of gender-affirming hormones on the mental health and well-being of transgender and nonbinary youth “would appear crucial, given the documented mental health disparities observed in this population, particularly in the context of increasing politicization of gender-affirming medical care.”
Over the last two years, state legislatures have considered dozens of bills that seek to restrict access to gender-affirming medical care, such as puberty blockers, hormone therapy and surgery for transgender minors.
Governors in four states — Arkansas, Alabama, Tennessee and Arizona — have signed restrictions on such care into law, but measures in Arkansas and Alabama have been blocked from taking effect by federal judges pending litigation.
So far this year, lawmakers have introduced such legislation in at least 16 states.
Supporters of this legislation argue that the care is experimental and that minors are too young to make decisions about medical care that could have irreversible impacts.
These groups point to the growing body of research that has found the care to have significant positive mental and physical health effects for transgender youth, who have disproportionately high rates of suicide.
A national survey released last year by the Trevor Project, a national youth suicide prevention and crisis intervention organization, found that more than half of transgender and nonbinary youth (53%) seriously considered suicide in the past year. Nearly 1 in 5 (19%) reported that they had attempted suicide in the past year.
In addition to the New England Journal of Medicine study, about half a dozen others have shown that access to puberty blockers and hormone therapy can improve mental health outcomes, including reducing suicidal ideation, among transgender youths.
And a 2021 study published in the Journal of Adolescent Health, which was based on data from the Trevor Project, found that gender-affirming hormone therapy is strongly linked to a lower risk of suicide and depression for transgender youths between the ages of 13 and 24.
The researchers behind the New England Journal of Medicine Study noted that there were some limitations to their study. For example, they recruited participants from gender clinics at children’s hospitals in Chicago, Boston and Los Angeles.
As a result, they said the findings might not apply to youth who cannot access comprehensive gender-affirming care or youth who are self-medicating with gender-affirming hormones.
They also noted that improvement in mental health varied widely, and that some participants continued to report high levels of depression and anxiety and lower levels of positive emotions and life satisfaction.
Two participants died by suicide during the study and six withdrew, according to the researchers. The information gathered before they died or left the study was included in the analyses, they added.
The study did not examine other factors that are known to affect psychosocial functioning among trans youth, such as parental support. The study also lacked a comparison group, which the researchers said limits their ability to establish causality. They plan to study those other factors and will continue to follow the cohort to see whether the improvements are sustained over a longer period of time.